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.

• Actual harm, isolatedF580Jun 21, 2022

  Based on observation, interview and document review the facility failed to notify the medical provider for guidance for 1 of 3 residents (R1) who sustained a head injury following a fall, who was on [MEDICATION(S)] (a blood thinner) and was complaining of a headache reviewed for falls. The facility's failure to contact the physician timely resulted in actual harm for R1 who required hospitalization and was diagnosed with C1-C2 fractures. The findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Jun 21, 2022

  Based on observation, interview and document review the facility failed to supervise and implement interventions to prevent a fall for 1 of 3 residents (R1) who had unknown history of Vasovagal [CONDITION(S)] ([CONDITION(S)] spell) reviewed for falls. This resulted in actual harm for R1 who sustained a head injury, was hospitalized , and was diagnosed with C1-C2 fractures. The findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired and had diagnoses which included abnormalities of gait and mobility, anxiety disorder, age-related physical debility, cognitive communication deficit, history of falling, long term use of anticoagulants (blood thinner), mild cognitive impairment, age-related [CONDITION(S)] with current pathological… […]

• No harm, potential for more than minimal, isolatedF677May 12, 2026

  Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., nail care) was completed and provided for 1 of 1 resident (R7) reviewed for activities of daily living (ADLs) and who was dependent on staff for their care.Findings Include:R7's comprehensive Minimum Data Set (MDS) assessment, dated 4/3/26, identified R7 had severe cognitive impairment, and was dependent for personal hygiene which include nails care.R7's care plan dated 3/8/24 indicated bath and nailcare will be offered by nurse aid every week. R7s electronic medical record (EMR) lacked weekly nail care provided with baths. Facility Nursing Assistant Bath Day sheet dated 5/7/26 indicated nails were cleaned and not needed to be clipped. […]

• No harm, potential for more than minimal, isolatedF684Feb 12, 2025

  Based on observation, interview, and record review the facility failed to comprehensively assess and monitor high blood pressure and rectal bleeding for 1 of 3 residents (R2) reviewed for change in condition. Findings include The American Heart Association (AHA) defines hypertensive crisis as a systolic blood pressure higher than 180 and/or diastolic pressure higher than 120. Blood pressure in this range can result in but not limited to stroke, heart attack, loss of kidney function, and aortic dissection. AHA directs for blood pressures that meet this criteria to wait at least 1-2 minutes and take the blood pressure again and consult your doctor immediately. […]

• No harm, potential for more than minimal, isolatedF554Jan 25, 2024

  Based on observation, interview, and document review, the facility failed to assess resident for safety and the ability to self-administer medications (SAM) for 1 of 1 resdient (R99) with nebulizer treatment. Findings include: R99's medical diagnoses indicate R99 with hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of right dominant side due to a stroke), dysphagia (inability to swallow food or liquid), aphasia (damage to the speaking or language areas of the the brain), depression, diabetes, and chronic obstructive pulmonary disease. […]