Good Shepherd Health Center

In the surveyor’s words

From the most serious findings on record at Good Shepherd Health Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Feb 3, 2021

  Based on observation, clinical record review, staff and senior center staff interview, facility video footage review and facility policy review, the facility failed to ensure staff maintained a safe and secure environment for 1 of 4 residents reviewed who were at an elopement risk, (Resident #1) which resulted in immediate jeopardy to resident health and safety. On 1/14/21 at 11:22 am Resident #1 left through door 4 on the 2nd floor, went down 2 flights of cement stairs and left the building out of door 1 on the 1st floor. The door alarm on the 2nd floor did not sound as it was shut off. The door alarm on the 1st floor sounded but the alarm panel showed door 3. […]

• Immediate jeopardy, isolatedF684Aug 30, 2024

  Based on observation, clinical record review, facility policy review, family, physician, emergency medical personnel, and staff interview, the facility failed to implement interventions in a timely manner for a resident following a fall for 1 of 3 residents reviewed (Resident #3). The facility failed to intervene after Resident #3 fell and complained instantly of new pain to his ribs. Despite, the family's frequent questioning about Resident #3's situation, the facility failed to send him to the hospital for 2 hours and 36 minutes following his fall. The facility's policy requires someone from nursing management to assess a resident following an incident. It took the nursing supervisor approximately 1 hours after Resident #3 fell for the nursing supervisor assessed Resident #3. […]

• Actual harm, isolatedF713Mar 13, 2025

  Based on observation, clinical record review, staff interview, and facility policy/procedure review at the time of the investigation, the facility failed to intervene timely for a resident who needed had a change in condition following a fall on 2/3/25 for 1 of 4 residents reviewed (Resident #2). At Resident #2's admission in December 2024, he came to the facility with a repaired fractured right hip due to a fall at home. Due to his cognition, he frequently forgot he previously had a hip fracture and would frequently transfer by himself. On 2/3/25, he had an unwitnessed fall. When the nurse assessed him, he reported pain to his right hip. After the nurse's assessment, 2 Certified Nurse Aides (CNAs) assisted Resident #2 from the floor and back into bed. […]

• Actual harm, isolatedF689Feb 21, 2023

  Based on observation, clinical record review, staff, physician and family interview, the facility failed to protect a resident against burn hazards from the heating elements in their rooms by placing a residents bed parallel to the heater in their room for 1 of 5 residents reviewed (Resident #3). On 1/26/23 Resident #3 rolled out of low bed and was found by staff with body on top of the heater with the skin of the right ear, neck and upper thigh touching the heater. The facility identified a census of 159 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 11/30/22 indicated Resident #3 had diagnoses that included Non-traumatic brain dysfunction, Non-Alzheimer Dementia, cataracts, glaucoma, muscle weakness and age-related physical debility. […]

• No harm, potential for more than minimal, widespreadF732Jul 6, 2023

  Based on observation, interview, and document review, the facility failed to post daily staffing in a clear and readable format and in a prominent place readily accessible to residents and visitors. The facility also failed to include the daily census on the posting. Findings include: Observation and interview on 7/5/23 at 2:52 PM revealed that the Scheduler (SCHR) had to show the surveyor where the Daily Staffing Report was located. The location was in the main lobby on a side hallway bulletin board that was completely filled. The SCHR stated, This could easily be missed depending on which hall you were going to, and it was not posted on the second floor. I am not informed of the daily census, and I have never put that on the report. […]