Good Shepherd Services LTD

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF887Aug 26, 2026

  Based on interview and record review, the facility did not ensure COVID-19 vaccines were offered or administered for 4 residents (R) (R5, R8, R14, and R19) of 8 sampled residents. R5, R8, R14, and R19's medical records did not indicate they were offered or administered COVID-19 vaccines. Findings include: The facility's COVID-19 Vaccine Residents policy, dated March 2023, indicates: All residents will be offered the COVID-19 vaccine to aid in preventing COVID infections. 1. R5 was admitted to the facility on [DATE] and had diagnoses including falls and diabetes. A Minimum Data Set (MDS) assessment, dated 7/29/26, stated R5 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating intact cognition. […]

• No harm, potential for more than minimal, patternF880May 29, 2025

  Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 31 residents residing in the facility. The facility did not have a detailed flow diagram of the facility's water system that identified areas where Legionella could grow. The facility's infection control policies were incomplete and/or did not contain current information. R17 was on EBP due to the presence of non-intact skin after R17's percutaneous endoscopic gastrostomy (PEG) tube (feeding tube via stomach) was removed. […]

• No harm, potential for more than minimal, patternF609May 26, 2021

  Based on interview and record review, the facility did not ensure that four allegations of abuse were reported to the State Survey and Certification Agency for 2 Residents (R) (R222 and R9) of 7 residents reviewed during the survey. On 12/07/2020, R222 accused two staff members of physical abuse. R222 reported being hit by two staff members. This allegation of abuse was not reported to the State Survey and Certification Agency. On 01/13/2021, 01/29/2021 and 05/03/2021, R9 verbalized allegations of sexual abuse. These allegations of abuse were not reported to the State Survey and Certification Agency. Findings include: 1. […]

• No harm, potential for more than minimal, patternF610May 26, 2021

  Based on interview and record review, the facility did not ensure that four allegations of abuse were thoroughly investigated for 2 Residents (R) (R222 and R9) of thirteen sampled residents. On 12/07/2020, R222 accused two staff members of physical abuse. R222 reported being hit by two staff members. This allegation of abuse was not thoroughly investigated. On 01/13/2021, 01/19/2021 and 05/03/2021, R9 verbalized allegations of sexual abuse. These allegations were not thoroughly investigated. […]

• No harm, potential for more than minimal, patternF656May 26, 2021

  Based on interview and record review, the facility did not develop a comprehensive person - centered care plan to meet the residents' medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. This had the potential to affect 4 of 13 residents sampled. R9 did not have a care plan to address the use of a antipsychotic and diuretic medication. R13 did not have a care plan to address the use of an antipsychotic and antidepressant medication. R20 did not have a care plan to address the use of an antipsychotic and anti-anxiety medication. R24 did not have a care plan to address the use of an antipsychotic and antidepressant medication. […]