Good Shepherd Lutheran Community

In the surveyor’s words

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

• Actual harm, isolatedF689May 26, 2026

  License Reference Number 175 NAC 12-006.09(I)Based on observation, interview, and record review the facility failed to implement interventions to prevent potential accidents for 3 (Residents 37, 55, and 57) of 3 sample residents. The facility census was 62.Findings are: A. Record Review of the facility's undated policy Safe Resident Handling/transfers revealed the following: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize the risks for injury and provide and promote a safe, secure and comfortable environment for the resident while keeping the employees safe in accordance with current standards and guidelines. […]

• No harm, potential for more than minimal, widespreadF732May 26, 2026

  Based on observation, record review and interview, the facility failed to ensure that the posted nurse staffing information contained the required information related to the facility census, the total number of hours worked per discipline per shift and the total number of hours worked for the each shift. This had the potential to affect all residents that resided in the facility. The facility census was 62. Findings are:Record review of an undated facility policy entitled Posting Direct Care Daily Staffing Numbers revealed the following information:Policy Explanation and Implementation:Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. 2. […]

• No harm, potential for more than minimal, widespreadF812May 26, 2026

  Licensure Reference Number 175 NAC 12-006.11 Based on observation, interview, and record review the facility failed to ensure hand hygiene was completed between 2 (Residents 58 and 62) of 2 sampled residents during dining service and failed to perform hand hygiene when indicated during food prep. This had the potential to affect all residents but 1 resident in the facility. The facility census was 62. Findings are: A. RR of the facility's undated Handwashing Guidelines for Dietary Employees policy revealed the following: 6. […]

• No harm, potential for more than minimal, widespreadF838May 26, 2026

  Based on record review and interview, the facility failed to ensure that the facility assessment included information related to staffing levels needed for specific shifts, a plan to maximize recruitment and retention of direct care staff and a contingency plan for events that do not require the activation of the facility emergency plan but have the potential to impact resident care. This had the potential to affect all residents that resided in the facility. The facility census was 62. […]

• No harm, potential for more than minimal, widespreadF812May 1, 2025

  Licensure Reference Number 175 NAC 12-006.11 E The facility failed to ensure hand hygiene and gloving were performed in a manner to prevent the potential for food borne illness and failed to maintain the cleanliness and condition of shelving units, serving windows, equipment, floors, ventilation systems, and storage carts in the facility kitchen. This had the potential to affect 66 residents in the facility that ate foods prepared in the facility kitchen. The facility census was 66. Findings are: A. Record review of a facility policy entitled Hand Washing dated 3/19/2020 revealed the following: Hand hygiene will be performed for a minimum of 20 seconds. Procedures: Guidelines on when to perform hand hygiene may include - before preparing or handling food. […]