Good Shepherd Lutheran Home

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF572Jul 9, 2026

  Based on observation, interview, and record review, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was displayed for residents, visitors, and staff to review. This had the potential to affect all residents currently residing in the facility, as well as all staff and visitors. Findings include: On 7/8/26 at 8:47 a.m., it was observed that RBOR poster was displayed in a locked glass case in a small common area near the entrance and was dated 1/16. On 7/8/26 at 12:02 p.m., director of Social Services confirmed the poster was outdated and a new one needed to be ordered. A facility policy was requested but none provided.

• No harm, potential for more than minimal, widespreadF732Apr 17, 2025

  Based on record review and interviews, the facility failed to ensure all required data were included on the nurse staffing information posted daily. This had the potential to affect all 114 residents residing in the facility and their visitors who may wish to view the information. Findings include: On 4/14/25 at 1:21 p.m., the posted nurse staffing information dated 4/14/25, was observed in a clear, plastic cover on the visitor sign-in table. However, the nurse staffing information lacked the total number and the actual hours worked by categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. […]

• No harm, potential for more than minimal, widespreadF867Apr 17, 2025

  Based on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement Program (QAPI) committee effectively sustained ongoing compliance related to repeat citations from past surveys regarding drug storage. This had the potential to affect all 114 residents residing in the facility. Findings include: Review of the facility CASPER Report dated 3/17/25, indicated the facility was cited F761 for drug storage on the survey exited 5/2/24. See F761: Based on observation and interview, the facility failed to maintain safe storage of medications when medication carts were left unlocked and unattended in 2 of 7 medication carts. […]

• No harm, potential for more than minimal, patternF812Apr 17, 2025

  Based on observation, interview, and document review, the facility failed to ensure food and beverages stored in the refrigerators and freezers were labeled, dated and discarded properly. In addition, the facility failed to maintain the ice machines in a sanitary manner to prevent potential food-borne illness. This deficient practice had the potential to affect all 116 residents who received food, beverages, and ice from the refrigerators, kitchen and ice machine. Findings include: On 4/14/25 at 10:44 a.m., during the kitchen tour with the dietary supervisor (DS), the following concerns were identified: Produce cooler: -1/4 container of yogurt without notation of an open date. -3/4 container tartar sauce without notation of an open date. […]

• No harm, potential for more than minimal, patternF610May 2, 2024

  Based on interview and document review the facility failed to maintain records of a thorough investigation for 4 of 4 residents (R29, R318, R319, R50) related to facility reported events. Findings include: On 8/30/23 at 11:42 a.m., the facility submitted an incident report to Minnesota Department of Health (MDH) regarding possible allegations of financial exploitation for R29. R29 had reported her tablet had been missing, and after searching felt someone had taken it. Report indicated that Sauk Rapids police department (PD) had been notified, and no alleged perpetrator (AP) had been identified. On 9/6/23 at 4:32 a.m., the facility submitted a five day incident report to MDH with an overall summary of the event and their investigation summary. […]