Good Shepherd Home

In the surveyor’s words

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

• Actual harm, isolatedF689May 16, 2022

  Based on medical record review, staff interviews, and review of facility policy, the facility failed to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in actual harm when a resident experience repeated falls, with one resulting in a fracture requiring surgery. This affected one resident (#46) out of four residents reviewed for falls. The census was 89. Finding include: Review of the medical record for Resident #46 revealed the resident was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF761May 18, 2026

  Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure medications were were properly stored, labeled, and dated. This had the potential to affect all 80 residents residing in the facility. The facility census was 80.Review of the medical record for Resident #73 revealed an admission on [DATE]. Diagnoses included allergic rhinitis, hypertensive heart disease with heart failure, and anxiety disorder. Review of the physician's order dated 05/06/26 revealed an order for ipratropium bromide nasal solution 0.03 percent (%) for two sprays in both nostrils every 24 hours as needed for rhinitis related to allergic rhinitis.Review of the medical record for Resident #71 revealed an admission on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812May 18, 2026

  Based on observation, staff interview, and policy review, the facility failed to ensure food was prepared and stored in a safe and sanitary manner. This affected all 77 residents who received food from the kitchen. The facility identified three (#4, #60, and #61) residents received nothing by mouth. The facility census was 80.Findings included:1. Observation of the facility kitchen on 05/11/26 at 7:45 A.M. revealed Dietary Aide (DA) #195 was in the kitchen pouring drinks and assisting with breakfast preparation. DA #195 was noted to have a long beard and hair. His hair was covered with a hairnet, but his beard was not covered.Interview with [NAME] #190 on 05/11/26 at 7:50 A.M. […]

• No harm, potential for more than minimal, widespreadF880May 18, 2026

  Based on observation, medical record review, review of infection control documents, staff interview, and review of facility policy, the facility failed to ensure resident infections were adequately tracked for potential trends, failed to ensure residents with wounds were in enhanced barrier precautions, and failed to ensure resident equipment used to inhale medications were kept and stored in a sanitary manner. This had the potential to affect all 80 residents residing in the facility. The facility census was 80.Findings include: 1. Review on 05/18/26 at 9:00 A.M. of the facility's infection control surveillance plan for April 2026, revealed there was no surveillance of the bacteria found in the infections identified. […]

• No harm, potential for more than minimal, widespreadF812Oct 10, 2024

  Based on observation, staff interview, and policy review, the facility failed to store foods properly in the refrigerator and failed to discard expired food items. This had the potential to affect all 83 residents who the facility identified received food from the kitchen. The facility census was 83. Findings include: 1. Observation of the main kitchen refrigerator on [DATE] at 8:10 A.M. revealed there was a container of thickened pudding dated [DATE] and a container of thickened juice dated [DATE] which were outdated and failed to be discarded. Observation of the walk in refrigerator on [DATE] at 8:23 A.M. revealed a box of sliced mushrooms were on a wire shelf and were open to air. […]