Good Shepherd Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 7, 2026

  Based on record review and staff interviews the facility failed to provide an environment free from accident hazards by not assessing the need for hand rail assist bars. This failure created an immediate jeopardy situation and caused the entrapment of one resident who was found deceased with their head and arm between the hand rail and mattress. This failed practice had the potential to affect all residents residing in the long term care facility because all residents except one (1) have the bilateral hand rail assist bar. Resident identifier: #100. Facility census: 174. […]

• No harm, potential for more than minimal, patternF700May 7, 2026

  Based on staff interviews, observation and document reviews, the facility failed to complete an accurate bed rail assessment for a resident.The current assessment did not fully assess resident's risks/needs for side rails. This was true for Resident #100. and had the potential to affect more than a minimal number of residents residing in the long term care facility. Facility Census: 174. Findings included: a) Resident #100During an interview with Facility Administrator on 05/06/26 at 3:27 PM, she reported new beds had recently been obtained for everyone but bariatric residents in the facility and denied that any resident had been assessed for need of bed rails. […]

• No harm, potential for more than minimal, patternF585Aug 22, 2025

  Based on staff interview, resident interviews, and observation the facility failed to ensure residents knew they had the right to file grievances anonymously. This deficient practice had the potential to affect more than a limited number of residents. Facility Census: 181 Findings included: a) Resident #470 and #26 During facility entrance observation and resident interviews on 08/18/25 at approximately 2:40 PM, Resident #470 stated she did not know how to file a grievance anonymously.In an interview with Resident #26 On 08/18/25 at 2:53PM, She stated she did not know how to file a grievance/complaint anonymously.Based on a record review of Section C of the most recent Minimum Data Set (MDS) records, both Residents #470 and #26 had capacity and was cognitively intact. […]

• No harm, potential for more than minimal, patternF689Aug 22, 2025

  Based on observation and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and that the resident received adequate supervision and assistance devices to prevent accidents. Mounted wall heaters had maintenance access panel covers missing exposing thin sharp metal edges, wires and hot pipes in 3 (three) resident rooms. This failed practice was a random opportunity for discovery. Resident identifiers #58, #146, #33, and #74. Facility Census: 181. […]

• No harm, potential for more than minimal, patternF725Aug 22, 2025

  Based on record review, staff interviews and resident interviews, the facility failed to ensure residents receive the help and care they need without waiting long periods of time. This deficient practice had the potential to affect more than a limited number of residents. Resident identifiers: #86, #181, #161, #23, #400, #19, #48, #86, #45, and #99. Facility Census: 181Findings included:a) On 08/18/25 at 2:53PM, In an interview with Resident #26, She stated on Sunday(08/19/25) she had to wait 45 minutes to get staff to take her to the restroom and stated she was going to soil herself. She said I know I wear briefs, but it is not comfortable to wet in them. I try not to if I can help it. […]