Every finding on record at Good Shepherd Services LTD

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. On 8/26/26, Surveyor reviewed R5's vaccination record which did not indicate they were offered or administered an updated COVID-19 vaccine. On 8/26/26 at 1:49 PM, Surveyor interviewed R5 who indicated they wanted all vaccines because they were aging and wanted to stay healthy. (See interview under example 4.) 2. R8 was admitted to the facility on [DATE] and had diagnoses including encephalopathy and cerebral infarction. An MDS assessment, dated 6/24/26, stated R8 had a BIMS score of 4 out of 15, indicating severely impaired cognition. On 8/26/26, Surveyor reviewed R8's vaccination record which did not indicate they were offered or administered an updated COVID-19 vaccine. (See interview under example 4.) 3. R14 was admitted to the facility on [DATE] and had diagnosis including Lewy Body dementia. An MDS assessment, dated 6/17/26, stated R14 had a BIMS score of 0 out of 15, indicating severely impaired cognition. On 8/26/26, Surveyor reviewed R8's vaccination record which did not indicate they were offered or administered an updated COVID-19 vaccine. (See interview under example 4.) 4. R19 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure and encephalopathy. An MDS assessment, dated 7/9/26, stated R19 had a BIMS score of 2 out of 15, indicating severely impaired cognition. On 8/26/26, Surveyor reviewed R8's vaccination record which did not indicate they were offered or administered an updated COVID-19 vaccine. On 8/26/26 at 2:01 PM, Surveyor interviewed Director of Nursing (DON)-B who verified the facility was missing records to verify COVID-19 vaccines were offered or administered for R5, R8, R14, and R19.

Based on interview and record review, the facility did not ensure 2 residents (R) (R8 and R19) of 8 sampled residents received pneumococcal vaccines as indicated. The facility did not review R8's vaccination history and offer the PCV20 (Prevnar 20 vaccine) or influenza vaccine. The facility did not review R19's vaccination history and offer the PCV20 vaccine. Findings include: The facility's Pneumococcal Vaccine policy, dated March 2023, indicates: All residents will be offered the pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23) and pneumococcal conjugate vaccine (PCV20, Prevnar 20) to aid in preventing pneumococcal infection. The facility's Influenza Vaccine policy, dated March 2023, indicates: All residents and employees will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccination against influenza. 1. R8 was admitted to the facility on [DATE] and had diagnoses including encephalopathy and cerebral infarction. A Minimum Data Set (MDS) assessment, dated 6/24/26, stated R8 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severely impaired cognition. On 8/26/26, Surveyor reviewed R8's vaccination record which did not indicate they were offered or administered a PCV20 or influenza vaccine since 2024. (See interview under example 2.) 2. R19 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure and encephalopathy. An MDS assessment, dated 7/9/26, stated R19 had a BIMS score of 2 out of 15, indicating severely impaired cognition. On 8/26/26, Surveyor reviewed R19's vaccination record which did not indicate they were offered or administered a PCV20 vaccine since 2024. On 8/26/26 at 2:01 PM, Surveyor interviewed Director of Nursing (DON)-B who verified the facility was missing records to verify influenza and pneumococcal vaccines were offered or administered to R8 and R19. DON-B indicated vaccines should be offered on an annual basis.

Based on observation, interview, and record review, the facility did not ensure 1 resident (R) (R20) of 2 sampled residents received portion sizes in accordance with their daily ordered diet.R20's care plan contained a goal to consume 75% of their daily ordered diet. Staff deviated from R20's diet order and served half portions without their consent.Findings include:The facility's undated Nutrition Policy indicates: Good [NAME] Nursing Home will provide residents with meals and fluids that meet their nutritional and hydration needs while taking into consideration physician/provider orders, allergies, food preferences, and individual dietary needs .2. Resident food preferences, allergies, and special dietary needs will be identified and communicated to nursing and dietary staff .4. Residents will be provided meals and fluids appropriate to their needs and current orders .7. Nutritional and hydration concerns and interventions will be included in the resident's care plan when indicated. 8. Resident preferences and choices regarding food and fluids will be respected whenever possible while maintaining consideration of the resident's health and safety .On 8/25/26, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease and dementia. A care plan indicated R20 had a nutritional status goal to consume 75% of their ordered diet each day. The goal was initiated on 1/15/26 by Dietary Manager (DM)-C. On 8/25/26 at 11:50 AM, Surveyor observed [NAME] (CK)-E ask 5 residents if they wanted regular or small portions of food. For the residents who indicated they wanted a small portion, CK-E wrote small or sm next to the protein, starch, and vegetable on their meal tickets. Surveyor observed CK-E indicate to Assistant Dietary Manager (ADM)-D that R20 doesn't eat much and write small next to the protein, starch, and vegetable on their meal ticket. CK-E handed the meal ticket to ADM-D who was serving food. CK-E did not ask R20 their preference for food portions. Surveyor observed ADM-D serve unmeasured amounts (approximately half portions) of Swiss steak, roasted new potatoes, and mixed vegetables onto R20's plate. R20's meal ticket indicated they should receive a whole Swiss steak, 4 ounces of roasted new potatoes, and 4 ounces of vegetables.On 8/25/26 at 12:37 PM, Surveyor interviewed DM-C who indicated residents should be served the portion size listed on their meal ticket. DM-C indicated staff should let Registered Dietitian (RD)-F and Director of Nursing (DON)-B know if a resident wants smaller portions of food and they will assess and make changes as needed. DM-C indicated staff cannot arbitrarily decide that a resident should have smaller meal portions. On 8/25/26 at 12:46 PM, Surveyor interviewed ADM-D who indicated when they see small portions written on a resident's ticket, they automatically give them a half-size serving. On 8/25/26 at 12:58 PM, Surveyor interviewed CK-E who indicated R20 doesn't eat or talk a lot, however, they should not have made the determination for R20 that they should have smaller portions of food and should have asked R20's preference. CK-E indicated they used to run the kitchen and were used to approximately 75% of residents getting small portions of food. On 8/25/26 at 1:12 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated residents should be served the portion size that is on their meal ticket. NHA-A verified staff cannot decide on their own that a resident should be given a half-size portion of their meal.On 8/26/26 at 9:54 AM, Surveyor interviewed RD-F who thought serving sizes on meal tickets were used for the kitchen to determine how much food to buy and make. RD-F did not think meal ticket portions indicated serving sizes for residents. On 8/26/26 at 1:49 PM, Surveyor interviewed DM-C who agreed that if R20 only received 50% of their meal portions, they could not achieve their care plan goal of consuming 75% of their daily ordered diet. DM-C indicated the serving sizes on meal tickets are what residents should be served and are based on individual nutritional assessments and nutritional needs. DM-C indicated if a resident is supposed to receive double portions of protein for health reasons, it is indicated on their meal ticket and should be served as written. DM-C indicated meal tickets are part of a computerized system which also calculates the amount of food to purchase and make and is based on adding all of the individualized portion sizes to determine how much to order and how much to make in order to serve residents the portions that are specified on their meal tickets.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly and accurately investigated for 1 resident (R) (R1) of 3 sampled residents. On 4/15/26, R1 reported to Certified Nursing Assistant (CNA)-C that R1 was raped. Later that morning, R1 stated R1 was raped to Activities Director (AD)-D and Director of Nursing (DON)-B. The facility did not ensure the allegation of abuse was thoroughly and accurately investigated Findings include:The facility's undated Investigation of Allegation of Abuse, Neglect, Misappropriation of Property or Injury of Unknown Source policy indicates: After an allegation is made and initially reported, the facility will begin a thorough investigation to collect information that corroborates or disproves the incident and document the findings .a thorough investigation may include: collecting and preserving physical evidence, interviewing the alleged victim and witnesses, interviewing other residents to determine if they have been abused, interviewing staff who worked to determine if they were aware of the incident, and involving other regulatory authorities who may assist, including law enforcement.On 4/22/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including Lewy Body dementia with psychotic/mood disturbance and depression. R1's Minimum Data Set (MDS) assessment, dated 3/31/26, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R1 had severely impaired cognition. R1 had an activated Power of Attorney for Healthcare (POAHC). On 4/22/26 at 10:07 AM, Surveyor interviewed CNA-C regarding R1's allegation of abuse. CNA-C indicated during morning cares on 4/15/26 at approximately 7:00 AM, R1 stated R1 was raped two days prior. CNA-C ensured R1 was safe and immediately reported the allegation to Licensed Practical Nurse (LPN)-E and DON-B. On 4/22/26 at 10:44 AM, Surveyor interviewed DON-B who verified DON-B heard R1 make statements about being raped on 4/15/26 while R1 was in the common area. DON-B could not recall if staff reported the allegation to DON-B prior to DON-B hearing R1's statements. DON-B completed a skin assessment for R1 and updated R1's care plan. R1 also had a psych consult. DON-B did not think the facility interviewed other residents or staff and verified law enforcement was not notified.On 4/22/26 at 1:29 PM, Surveyor interviewed Executive Director (ED)-F who verified the facility did not complete additional staff or resident interviews. ED-F also verified the facility did not offer R1/R1's POAHC a sexual assault exam after the allegation because the facility believed it would be traumatic for R1. ED-F verified staff education was not completed related to reporting and investigating requirements.

Based on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of sexual abuse was not reported to local law enforcement or the State Agency (SA) for 1 resident (R) (R1) of 3 sampled residents. On 4/15/26, R1 reported to Certified Nursing Assistant (CNA)-C that R1 was raped. Later that morning, R1 stated R1 was raped to Activities Director (AD)-D and Director of Nursing (DON)-B. The facility did not report the allegation of abuse to local law enforcement or the SA.Findings include:The facility's undated Investigation of Allegation of Abuse, Neglect, Misappropriation of Property or Injury of Unknown Source policy indicates: It is the obligation of any staff to report to the Director of Nursing (DON) or Nursing Home Administrator (NHA)/Executive Director (ED) any allegation of abuse .Notification of NHA/ED is to take place immediately as soon as the allegation is made, reported, or discovered .all allegations of abuse must be sent to the Division of Quality Assurance (DQA) immediately. The investigation is to include notification to outside authorities such as law enforment and Adult Protective Services (APS) as applicable. On 4/22/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including Lewy Body dementia with psychotic/mood disturbance and depression. R1's Minimum Data Set (MDS) assessment, dated 3/31/26, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R1 had severe cognitive impairment. R1 had an activated Power of Attorney for Healthcare (POAHC). On 4/22/26 at 10:07 AM, Surveyor interviewed CNA-C regarding R1's allegation of abuse. CNA-C stated during morning cares on 4/15/26 at approximately 7:00 AM, R1 stated R1 was raped two days prior. CNA-C ensured R1 was safe and immediately reported the allegation to Licensed Practical Nurse (LPN)-E and DON-B. On 4/22/26 at 10:36 AM, Surveyor interviewed LPN-E who indicated LPN-E knew about the allegation but didn't do anything further since DON-B was aware.On 4/22/26 at 10:44 AM, Surveyor interviewed DON-B who verified DON-B heard R1 make statements in the common area on 4/15/26 about being raped. DON-B could not recall if staff reported the allegation to DON-B prior to DON-B hearing the statements. DON-B verified the incident was not reported to local law enforcement or the SA. DON-B indicated the facility typically reports allegations of rape or sexual abuse.On 4/22/26 at 1:29 PM, Surveyor interviewed Executive Director (ED)-F who indicated ED-F was notified of R1's allegation of rape during a behavior meeting on 4/15/26 at 11:00 AM. ED-F verified the allegation was not reported to law enforcement or the SA due to concerns for R1's psychological distress regarding a potential investigation, police involvement, and/or hospitalization. ED-F verified the facility typically reports allegations of abuse, neglect, and misappropriation to local law enforcement (if applicable) and the SA.

Based on staff interview and record review, the facility failed to ensure 1 resident (R) (R5) of 12 sampled residents was free from misappropriation of property.R5 reported to staff on [DATE] that on the morning of [DATE], R5 and R5's responsible party (child) noticed $276.00, a McDonald's gift card, and a Starbucks gift card were missing from R5's walker. An agency staff admitted to taking the money and gift cards.Findings include:Review of the facility's Investigation of Allegation of Abuse, Neglect, and Misappropriation of Property or Injury of Unknown Source policy indicates: Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, or legal guardians, friends, or other individuals .Abuse Prevention: .2. Training: Staff shall receive appropriate training in interventions, reporting, detection, and what constitutes abuse, neglect, and misappropriation. 3. Prevention: .(b) Implement procedures that identify, correct, and intervene in situations likely to result in abuse, neglect, and misappropriation of resident property . Review of R5's admission Record revealed R5 was initially admitted to the facility on [DATE] with diagnoses that included type two diabetes and rheumatoid arthritis. Review of R5's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], revealed R5 was assessed with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 whic indicated R5's cognitive function was intact. Review of a facility-reported incident submitted to the State Agency revealed R5 reported to staff on [DATE] at 10:07 AM that on the morning of [DATE], R5 and R5's responsible party (child) noticed $276.00, a McDonald's gift card, and a Starbucks gift card were missing from R5's walker. The police were contacted.Review of the facility's Investigation Report, dated [DATE], indicated an agency Certified Nursing Assistant (CNA) admitted to taking the money and gift cards. On [DATE], a police officer stated the agency CNA returned the gift cards and an amount of cash that was not consistent with the missing amount.During an interview on [DATE] at 3:30 PM, the Executive Director (ED) stated she was the Interim Administrator and the individual who the previous Nursing Home Administrator reported to. The ED stated the facility requires a background check and a tuberculosis (TB) test for agency staff and checks their professional license, COVID-19 vaccination, and Cardiopulmonary Resuscitation (CPR) certification prior to their first shift. The ED stated the facility doesn't require training for agency staff and it's the agency's responsibility to ensure training is provided, including abuse, neglect, and misappropriation training. The ED indicated the facility did not allow CNA 1 to return to the building following the incident except to speak to the police and former Administrator. The ED indicated the facility continues to use agency staff and does not require documentation of training for abuse, neglect, and misappropriation from the agency. The ED stated the facility does their own abuse, neglect, and misappropriation training annually (which includes a post-test) and upon hire/orientation with regular staff.Telephone calls to R5 on [DATE] at 4:00 PM and 5:00 PM were not returned.

Based on staff interview and record review, the facility failed to protect 3 residents (R) (R1, R2, and R4) of 12 sampled residents from physical abuse. On 12/4/25, R1 accused R2 of being in R1's home and aggressively grabbed R2's right wrist and squeezed it. R2 had bruising on the right hand and wrist. R1 had a bruise and skin tear on the left hand. On 12/9/25, R1 stuck R1's leg out to trip R4 and grabbed R4's right hand/wrist. R4 had two bruises on the right hand. Findings include:Review of the facility's Investigation of Allegation of Abuse, Neglect, and Misappropriation of Property or Injury of Unknown Source policy indicates: Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, or legal guardians, friends, or other individuals .1. Review of R1's admission Record revealed R1 was admitted to the facility on [DATE] with diagnoses that included dementia and anxiety disorder. Review of R1's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/26/25, revealed R1 was assessed with a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R1's cognitive function was severely impaired.Review of R2's admission Record revealed R2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and dementia. Review of R2's Annual MDS assessment, with an ARD of 12/17/25, revealed R2 was assessed with a BIMS score of 00 out of 15 which indicated R2's cognitive function was severely impaired.Review of a facility-reported incident, dated 12/4/25, revealed at approximately 5:30 PM on 12/4/25, the nurse on duty witnessed R1 and R2 at the end of the hallway. The nurse indicated the residents appeared to be arguing and R1 was holding and aggressively squeezing R2's right wrist. R2 had a bruising on the right hand and wrist. Review of a progress note, dated 12/4/25 and written by Licensed Practical Nurse (LPN) 1 indicated R1 had R2's right wrist in R1's right hand. R2 had a bruise on the wrist. R1 and R2 could not give an account of the incident. R1 thought R2 was trespassing in R1's room.Review of a progress note, dated 12/5/25 and written by LPN 2, indicated R1 had a reddish-purple bruise and a skin tear on top of the left hand.During an interview on 3/19/26 at 4:01 PM, LPN 1 stated LPN 1 witnessed R1 grab R2's right wrist on 12/4/25 at approximately 6:00 PM. LPN 1 immediately notified the Administrator and the Director of Nursing (DON) and indicated the police were called.2. Review of R4's admission Record revealed R4 was admitted to the facility on [DATE] with diagnoses that included dementia and anxiety disorder.Review of R4's Quarterly MDS assessment, with an ARD of 9/17/25, revealed R4 had a BIMS score 00 out of 15 which indicated R4's cognitive function was severely impaired.Review of a facility-reported incident, dated 12/9/25, revealed staff witnessed R1 stick R1's leg out in front of R4's wheelchair as if to trip R4. Staff also witnessed R1 become aggresive, grab R4's right hand/wrist, and refuse to let go. R4 stated R1 was hurting R4. R4 had two bruises on the right hand but could not recall what happened. A progress note, dated 12/9/25, revealed Registered Nurse (RN) 3 indicated R4 was in the hallway when R1 attempted to trip R4 and grabbed R4's right hand. R4 called out and stated, Let go. You're hurting me. R4 had 2 bruises on the right hand.During an interview on 3/19/26 at 4:01 PM, LPN 1 indicated LPN 1 witnessed R1 grab and try to trip R4 and also grab R4's right wrist. LPN 1 separated the residents.

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. Certified Nursing Assistant (CNA)-G and CNA-H did not wear personal protective equipment (PPE) during high-contact resident cares, including changing linens and shaving R17. R4's chronic wound reopened on 5/25/25, however, R4 was not placed on EBP until the 5/28/25 PM shift. Findings include: The facility's undated Legionella Policy and Procedure for Water Management indicates: Purpose: To provide a structured plan of action for the prevention of Legionella growth and spread. To assure the safety of all residents and staff. Policy: To establish a procedure as a guide to check and clean equipment; maintenance staff will initiate general precautions to prevent the growth of Legionella bacteria in water lines and systems .3. A detailed drawing of the building water supply will be maintained by the Building and Grounds Department. The facility's Isolation-Categories of Transmission Based Precautions policy, revised April 2024, indicates: .2. Enhanced barrier precautions (EBP), in addition to standard precautions (SP) .will be implemented for residents with targeted multi-drug resistant organisms (MDRO) infections, indwelling medical devices, and wounds, including as part of a public health containment response. A. Examples of infection requiring EBP include, but are not limited to: 1. Wounds. 2. Any skin opening requiring a dressing. 3. Device care or use; central line, urinary catheter, feeding tube, tracheostomy .c. Gown and Gloves: 1. In addition to SP, staff need to wear a gown and gloves during specific high-contact resident care activities for those identified as being at risk for MDRO transmission. 2. Remove gown and gloves before leaving the room and perform hand hygiene immediately .e. Orange Contact Precaution Sign: 1. When a resident is placed on enhanced barrier precautions an orange sign will be used to alert staff to the implementation of transmission-based precautions. The sign will be placed at the entrance/doorway of the resident's room. 1. On 5/29/25, Surveyor reviewed the facility's Legionella Policy and Procedure for Water Management and noted the policy did not include a detailed flow diagram of the the facility's water system. On 5/29/25 at 10:22 AM, Surveyor interviewed Maintenance Director (MD-K) who did not have a detailed flow diagram of the facility's water system that identified areas where Legionella could grow. MD-K indicated if Legionella control measures were not met, the facility would follow the emergency management contaminated water policy. MD-K did not have corrective actions specific to situations when Legionella control measures were not met. 2. On 5/29/25, Surveyor reviewed the facility's infection control policies and procedures. Surveyor noted the facility's policies were not reviewed and updated annually and also noted the following: ~ The facility's Pneumococcal Vaccines policy, dated March 2023, did not include information about the 15-valent pneumococcal conjugate vaccine (PCV-15) or the 21-valent pneumococcal conjugate vaccine (PCV-21). ~ The facility's Influenza Vaccine policy, dated March 2023, did not address how to protect residents from communicable disease from staff with symptoms of respiratory illness. ~ The facility's Influenza Vaccine and COVID-19 Vaccine Employees policies, dated March 2023, did not address the procedure for staff who refuse vaccinations. ~ The facility's Outbreak of Communicable Diseases policy, dated May 2025, addressed gastroenteritis and acute respiratory infection but did not include information about other communicable diseases. In addition, the policy referenced an outdated State of Wisconsin Department of Health Services Memo re: Reporting and control of Acute Respiratory Illness Outbreaks in Long Term Care Facilities document, dated December 13, 2021. The facility's Isolation-Categories of Transmission Based Precautions, policy, dated April 2024, did not specify which multidrug-resistant organisms (MDROs) were being targeted for enhanced barrier precautions. On 5/29/25 at 2:15 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed the facility's infection prevention policies and procedures were incomplete and needed to be updated. DON-B indicated DON-B planned to update the policies as part of DON-B's Infection Preventionist responsibilities. DON-B indicated DON-B did not have a comprehensive list of communicable diseases that must be reported to the health department and stated DON-B had been reporting communicable diseases based on DON-B's personal knowledge of the reporting requirements. 3. From 5/27/25 to 5/29/25, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including dementia, cellulitis (bacterial skin infection) and dysphagia (difficulty swallowing). R17's Minimum Data Set (MDS) assessment, dated 5/21/25, had a Brief Interview for Mental (BIMS) score of 9 out of 15 which indicated R17 had moderate cognitive impairment. R17 had an activated Power of Attorney for Healthcare (POAHC). On 5/27/25 at 10:17 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who indicated R17 was on EBP due to open skin after R17's PEG tube was removed. Surveyor observed an EBP sign and PPE cart outside R17's room. On 5/27/25 at 10:25 AM, Surveyor observed CNA-G and CNA-H change R17's linens and shave R17's face with an electric razor without wearing PPE. On 5/27/25 at 11:50 AM, Surveyor interviewed CNA-H who confirmed CNA-H shaved R17's face, brushed R17's hair, and washed R17's glasses without wearing PPE. CNA-H indicated PPE only needed to be worn when CNA-H was in contact with R17 which was what CNA-H was told. CNA-H indicated R17 was on EBP due to a wound. CNA-H indicated CNA-H should have donned PPE, however, CNA-H did not have contact with R17's wound dressing. CNA-H indicated CNA-H did not think an infection could spread from shaving but would don PPE next time. CNA-H also indicated PPE should be worn during linen changes. On 5/28/25 at 12:53 PM, Surveyor interviewed DON-B who indicated CNA-G and CNA-H should have worn PPE if they completed high risk tasks such as dressing and undressing R17. DON-B indicated shaving was questionable, however, if a resident was on EBP staff should don the appropriate PPE. 4. On 5/27/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including chronic diastolic heart failure, metabolic encephalopathy, and chronic kidney disease. R4's MDS assessment dated [DATE] had a BIMS score of 12 out of 15 which indicated R4 had moderate cognitive impairment. R4 had an activated POAHC. On 5/27/25 at 10:36 AM, Surveyor observed a CNA transfer R4 into bed and reposition R4 without wearing PPE. Surveyor did not observe an EBP sign or PPE cart outside R4's room at that time. On 5/28/25, Surveyor did not observe an EBP sign or PPE cart outside R4's room. On 5/29/25 at 10:44 AM, Surveyor observed an EBP sign and a PPE cart outside R4's room. On 5/29/25 at 10:48 AM, Surveyor interviewed Registered Nurse (RN)-I who indicated R4 was placed on EBP on the 5/28/25 PM shift. RN-I stated EBP should be in place when a wound is identified. RN-I confirmed R4's wound was identified on 5/25/25. On 5/29/25 at 1:42 PM, Surveyor interviewed DON-B who indicated EBP should have been implemented the day R4's wound reopened. DON-B verified R4's wound reopened on 5/25/25 which was when EBP should have been implemented.

Based on staff and resident interview and record review, the facility did not ensure 2 residents (R) (R6 and R17) of 3 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, name and address with telephone number of the Office of the State Long-Term Care Ombudsman plus notification of discharges/transfers to the Ombudsman. In addition, the facility did not ensure R6 and R17 received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R6 was transferred to the Emergency Department (ED) on 5/16/25. R6 was not provided with a written transfer or bed hold notice. In addition, the facility did not notify the Ombudsman of R6's transfer. R17 was transferred to the hospital on 2/14/25. R17's representative was not provided with a written transfer or bed hold notice. In addition, the facility also did not notify the Ombudsman of R17's transfer. Findings include: The facility's Transfer Notices and Bed-Hold Rights Policy, dated 2025, indicates: .The resident and the resident's representative shall be given written notice of the bed-hold option at the time of the hospitalization or therapeutic leave .Medicare/Private Pay: .A copy of the bed-hold policy will be sent with the resident at the time of hospitalization. A copy will also be sent to the responsible party within 24 business hours . 1. From 5/27/25 to 5/29/25, Surveyor reviewed R6's medical record. R6's Minimum Data Set (MDS) assessment, dated 5/14/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R6 had intact cognition. R6 was responsible for R6's healthcare decisions. R6's medical record indicated R6 was transferred to the ED on 5/16/25 due to a toe injury. R6's medical record did not contain a written transfer or bed hold notice. On 5/27/25 at 10:47 AM, Surveyor interviewed R6 who indicated R6 was transferred to the ED due to bumping R6's toe. R6 did not recall if R6 signed a transfer or bed hold notice. On 5/28/25 at 8:57 AM, Surveyor requested the written transfer and bed hold notice for R6's hospital transfer on 5/16/25 from Director of Nursing (DON)-B. On 5/28/25 at 9:41 AM, DON-B indicated DON-B was trying to find R6's transfer and bed hold notice and was contacting the nurse who transferred R6. On 5/29/25 at 10:30 AM, Surveyor interviewed DON-B who showed Surveyor a voicemail text on DON-B's phone, dated 5/28/25, from Registered Nurse (RN)-F. The text message indicated RN-F filled out R6's transfer and bed hold forms, however, RN-F shredded the forms. RN-F indicated RN-F thought transfer and bed hold forms should only to be filled out if a resident was admitted to the hospital. On 5/29/25 at 11:21 AM, Surveyor a left message for RN-F but did not receive a return call. 2. From 5/27/25 to 5/29/25, Surveyor reviewed R17's medical record. R17's MDS assessment, dated 5/21/25, had a BIMS score of 9 out of 15 which indicated R17 had moderate cognitive impairment. R17 had an activated Power of Attorney for Healthcare (POAHC). R17's medical record included a transfer and bed hold notice and indicated R17 was transferred to the hospital on 2/14/25 due to cellulitis. The notice indicated verbal notification via phone was completed. R17's medical record did not indicate a written transfer and bed hold notice was given or mailed to R17 or R17's representative. On 5/28/25 at 9:37 AM, Surveyor received R17's written transfer and bed hold notice. DON-B indicated Social Worker (SW)-E ran a discharge report and sent the report to the Ombudsman. On 5/28/25 at 9:58 AM, Surveyor reviewed the facility's February 2025 discharge notifications sent to the Ombudsman and noted R17's name was not on the list. DON-B indicated the facility only notifies the Ombudsman of planned discharges and stated residents who are transferred with a bed hold and will be returning to the facility are not on the notification list. DON-B indicated the facility's transfer and bed hold policy is the same as the forms residents are given during transfers. On 5/29/25 at 9:32 AM, Surveyor interviewed RN-D who indicated when a resident is transferred to the hospital, the nurse is responsible for reviewing the transfer notice and bed hold policy with the resident or their representative and should either obtain verbal consent or have the form signed. RN-D indicated RN-D typically has the resident or their representative sign the form but does not give a copy of the form to the resident or their representative unless a copy is requested. RN-D was not sure if the resident and/or their representative should be given a copy or if a copy should be mailed. On 5/29/25 at 9:35 AM, Surveyor interviewed SW-E who indicated SW-E only notifies residents who have planned discharges. SW-E indicated SW-E sends an end of the month report of planned discharges, deaths, and hospital transfers to the Ombudsman only if the residents are not on a bed hold. SW-E indicated nurses should review and obtain signatures or verbal consent from the resident or their representative. SW-E indicated the resident and/or their representative should be provided with a copy. SW-E did not know if R17 or R17's representative received a copy of R17's transfer and bed hold notice. SW-E also indicated SW-E did not have documentation to indicate transfer or bed hold notices were provided to family and indicated that was the nurses' responsibility. SW-E confirmed based on the regulations, SW-E should have notified the Ombudsman of all transfers and discharges.

Based on staff interview and record review, the facility did not ensure 3 residents (R) (R6, R27, and R7) of 5 sampled residents had documentation that indicated the residents or their legal representatives were thoroughly informed in advance of the risks and benefits of prescribed psychotropic medication. R6 was prescribed diazepam (a benzodiazepine medication) for a diagnosis of anxiety. The facility did not obtain written consent from R6 for the medication. R27 was prescribed olanzapine (an antipsychotic medication) for nausea and vomiting. The facility did not ensure a written consent form was thoroughly reviewed and completed with R27's Power of Attorney for Healthcare (POAHC). R7 was prescribed lorazepam (an antianxiety medication), buspirone (an anxiolytic medication), and duloxetine (an antidepressant medication). The facility did not ensure a written consent form was thoroughly reviewed and completed with R7's POAHC. Findings include: The facility's undated Nursing Psychotropic Medication policy and procedure indicates: .Psychotropic medications are those medications that affect the mind and/or central nervous system. They are used to treat medical needs and can produce changes in behavior and mood .Consent forms will be signed for all psychotropic medications used in the facility .3. A resident/responsible party will be informed of the physician order for psychotropic medication by the nursing department or Social Services. Reasons for the order, possible side effects, and alternative methods attempted will be explained to the resident/responsible party. 4. A resident/responsible party will sign a consent form for psychotropic drug use. Phone/verbal consent will be used until signed consent can be placed in the chart. Verbal consent should be documented in the medical record as to who gave it and the date. 1. On 5/28/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including anxiety and muscle spasms. R6's Minimum Date Set (MDS) assessment, dated 5/13/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R6 had intact cognition. R6 was R6's own decision maker. R6 had a physician order for diazepam 5 milligrams (mg) three times daily for anxiety and muscle spasms with a start date of 12/12/24. The medication contained a black box warning (the strictest warning on the label of prescription drugs or drug products by the Food and Drug Administration (FDA) when there is reasonable evidence of an association of a serious hazard with the drug). R6's medical record did not contain a consent form for diazepam. On 5/28/25 at 2:35 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed a consent form for diazepam was not completed. 3. From 5/27/25 to 5/29/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including dementia and anxiety. R7's MDS assessment, dated 2/26/25, had a BIMS score of 11 out of 15 which indicated R7 had moderate cognitive impairment. R7 was deemed incapacitated on 5/20/24 and had an activated POAHC to assist with healthcare decisions. R7's current physician orders included the following medication with a black box warning: ~ Lorazepam 0.5 mg, give 0.5 mg by mouth two times daily related to anxiety. ~ Bupropion 75 mg, give 1 tablet by mouth two times daily for depression. ~ Duloxetine 20 mg, give 1 tablet by mouth once daily for agitation. R7's medication consent forms for lorazepam, bupropion, and duloxetine that were not initialed or dated on pages 1-3 to indicate R7's POAHC reviewed and understood the risks and benefits of the medication, including side effects and adverse reactions, and alternatives to treatment. The consent forms indicated verbal consent was obtained on 6/4/24 and expired on 8/4/24. The consent forms did not contain signatures after the expiration date of 8/4/24. On 5/28/25 at 12:40 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R7's medication consent forms were not initialed or dated. DON-B indicated all of the pages should be initialed and dated and R7's POAHC's signature should have been obtained. 2. From 5/27/25 to 5/29/25, Surveyor reviewed R27's medical record. R27 was admitted to the facility on [DATE] and had diagnoses including dementia and malignant neoplasm of the lung. R27's MDS assessment, dated 5/7/25, had a BIMS score of 5 out of 15 which indicated R27 had severe cognitive impairment. R27 had an activated POAHC. R27 was prescribed the following medication with a black box warning: ~ Olanzapine 5 mg, give 1 tablet by mouth once daily for nausea and vomiting (dated 5/1/25). R27's medical record did not contain an Informed Consent for Mediation form for olanzapine. On 5/27/25 at 1:33 PM, Surveyor interviewed NHA-A who verified an Informed Consent for Medication form for olanzapine was not completed.

Based on staff interview and record review, the facility did not ensure a care plan was revised for 1 resident (R) (R4) of 12 sampled residents. The facility did not revise R4's care plan to include a chronic wound that reopened on 5/25/25. R4's care plan also did not indicate R4 was on enhanced barrier precautions (EBP). Findings include: On 5/29/25 at 1:39 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated facility did not have a care plan policy. On 5/27/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including chronic diastolic heart failure, metabolic encephalopathy, and chronic kidney disease. R4's Minimum Data Set (MDS) assessment, dated 4/23/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R4 had moderately impaired cognition. R4 had an activated Power of Attorney for Healthcare (POAHC). R4's care plan, dated 5/19/24, did not indicate R4 had a wound or was on EBP. A progress note, dated 5/25/25 at 2:01 PM, indicated the wound had reopened. An order was requested from the physician to continue with Vashe soak and Nystatin to periwound and cover with gauze. Change every other day. A progress note, dated 5/27/25 at 9:34 PM, indicated the physician approved a request to clean left sacrum with Vashe, apply Nystatin, and cover with gauze and tape. On 5/29/25 at 10:48 AM, Surveyor interviewed Registered Nurse (RN)-I who indicated R4 had a chronic wound that closed on 5/24/25 and reopened on 5/25/25. RN-I indicated the physician was updated on 5/25/25 and orders were received. RN-I confirmed R4's care plan was not updated regarding the wound. RN-I also indicated R4 was placed on EBP on the 5/28/25 PM shift which was not added to R4's care plan. On 5/29/25 at 1:42 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated wound interventions and precautions should have been added to R4's care plan when the wound reopened on 5/25/25.

Based on observation, staff interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R21) of 2 sampled residents. R21's oxygen was not turned on per R21's continuous oxygen order. Findings include: On 5/28/25 at 12:49 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility did not have an oxygen use policy. From 5/27/25 to 5/29/25, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia (low level of oxygen). R21's Minimum Data Set (MDS) assessment, dated 3/5/25, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R21 had severe cognitive impairment. R21 had an activated Power of Attorney (POA). R21's medical record contained the following orders: ~ Continuous oxygen no more than 3 liters per minute (LPM) on all shifts to have oxygen saturation at 90% or above (dated 9/6/23). ~ Check skin behind ears for redness or skin breakdown with oxygen tubing change every Tuesday AM shift related to chronic obstructive pulmonary disease (COPD) (dated 5/1/25). ~ Change nasal cannula tubing, concentrator tubing, and nebulizer tube, mouthpiece, and chamber every Tuesday AM shift related to COPD. Make sure to date each (dated 5/1/25). On 5/27/25 at 11:28 AM, Surveyor observed R21 in a wheelchair in the hallway and noted R21 had a nasal cannula connected to a portable oxygen tank. The portable oxygen tank was not turned on and was set at 0. On 5/27/25 at 11:33 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who verified R21's portable oxygen tank was set at 0. LPN-C indicated R21's oxygen should be set at 2 liters per minute (LPM) continuously and Certified Nursing Assistants (CNA) were responsible for turning on the oxygen tank unless an adjustment was needed and they should notify the nurse. Surveyor observed LPN-C obtain R21's oxygen saturation level which was at 69% after LPN-C changed R21's oxygen setting to 2 LPM. LPN-C was unsure of R21's oxygen saturation parameter and stated LPN-C would follow-up with Surveyor. On 5/27/25 at 11:40 AM, LPN-C approached Surveyor and indicated R21's oxygen saturation level should be at 90% or above. Surveyor observed LPN-C recheck R21's oxygen saturation level which was at 97% on 2 LPM of oxygen. On 5/28/25 at 12:49 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R21 should use continuous oxygen via nasal cannula.

2. From 5/27/25 to 5/29/25, Surveyor reviewed R27's medical record. R27 was admitted to the facility on [DATE] and had diagnoses including dementia with malignant neoplasm of the lung. R27's MDS assessment, dated 5/7/25, had a BIMS score of 5 out of 15 which indicated R27 had severe cognitive impairment. R27 had an activated Power of Attorney (POA). A care plan (initiated 1/31/25) indicated R27 was at high risk for falls. R27's medical record indicated R27 fell on 5/11/25, 5/15/25, and 5/18/25 with no noted injuries. R27's care plan did not contain new interventions following the falls. A fall risk assessment, dated 5/19/25, indicated R27 was a high fall risk. On 5/29/25 at 1:33 PM, Surveyor interviewed NHA-A who indicated R27 should have had a new fall intervention added to R27's care plan following each fall. NHA-A verified fall interventions were not added to R27's care plan following the falls noted above. Based on observation, staff interview, and record review, the facility did not ensure the environment was free of accident hazards for 2 residents (R) (R26 and R27) of 4 sampled residents. R26 fell on 5/3/25, 5/10/25, and 5/16/25. The facility did not revise R26's care plan to help prevent future falls. In addition, R26's care plan contained an intervention for a fall mat when R26 was in bed. The intervention was not consistently implemented. R27 fell on 5/11/25, 5/15/25, and 5/18/25. R27's care plan was not updated after the falls and did not include interventions to prevent future falls. Findings include: The facility's undated Nursing Fall Policy and Procedure indicates: The fall report will be thoroughly completed by the nurse and a new fall intervention will be added to the resident's care plan and care card .Once completed, the fall report will be forwarded to the Director of Nursing. 1. From 5/27/25 to 5/29/25, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, cognitive communication deficit, and difficulty in walking. R26's Minimum Data Set (MDS) assessment, dated 2/26/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R26 had severe cognitive impairment. R26 had an activated Power of Attorney for Healthcare (POAHC). R26's care plan, dated 2/25/24, indicated R26 was at high risk for falls. R26's medical record indicated R26 fell on 5/3/25, 5/10/25, and 5/16/25 with no noted injuries. A fall risk assessment, dated 5/23/25, indicated R26 was a high fall risk. On 5/27/25 at 10:22 AM, Surveyor observed R26 asleep in bed with a fall mat on the floor next to R26's bed. On 5/28/25 at 2:03 PM, Surveyor observed R26 asleep in bed and noted R26's fall mat was under the bed. On 5/28/25 at 2:05 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-J who indicated R26's fall mat should be on the floor next to the bed when R26 is in bed. On 5/28/25 at 2:44 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated interventions should be added or revisions should be made to a resident's care plan following a fall. DON-B verified R26 had an intervention for a roll out mat placed at the bedside when R26 was in bed. DON-B verified R26's fall mat should be on the floor next to the bed when R26 is in bed. On 5/29/25 at 10:16 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated staff update DON-B of falls. NHA-A indicated DON-B reviews fall interventions and decides which interventions should be added to the care plan. NHA-A indicated the charge nurse adds interventions in the fall report and DON-B adds the interventions to the care plan the next day. NHA-A confirmed the process was not followed and stated staff are working on correcting the process. On 5/29/25 at 10:59 AM, Surveyor interviewed Registered Nurse (RN)-I who indicated R26 was at high risk for falls. RN-I stated staff complete frequent checks on R26 due to R26's fall history. RN-I indicated R26 did not use a call light for assistance. RN-I also indicated a fall mat was used when R26 was in bed during the day and at night. On 5/29/25 at 1:33 PM, Surveyor interviewed NHA-A who indicated R26 should have had a new fall intervention added to R26's care plan following each fall. NHA-A verified fall interventions were not added to R26's care plan following the falls noted above.

Based on staff interview and record review, the facility did not ensure the minimum required members of the facility's Quality Assessment and Assurance (QAA) committee met at least quarterly. This practice had the potential to affect all 31 residents residing in the facility. The facility did not have documentation that the minimum required members of the QAA committee met for quality assessment and assurance purposes on a quarterly basis. Findings include: On 5/29/25 at 8:56 AM, Surveyor reviewed the facility's QAA committee meeting sign-in sheets for the last four quarters and noted the QAA committee met on 7/19/24, 10/18/24, 1/17/25, and 4/18/25. Surveyor noted the minimum required committee members were not in attendance for two of the QAA meetings (7/19/24 and 4/18/25). The Director of Nursing (DON) who was also the Infection Preventionist (IP) did not attend the 7/19/24 or 4/18/25 QAA meetings. On 5/29/25 at 9:22 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the DON/IP was not present at the 7/19/24 and 4/18/25 QAA meetings.

Based on observation, staff interview, and record review, the facility did not provide appropriate care and services for 1 resident (R) (R28) of 1 sampled resident with an indwelling catheter. On 4/10/24, Surveyor observed R28's catheter drainage bag in direct contact with a floor mat without a barrier to prevent infection. Findings include: The facility's Nursing Care of an Indwelling Urinary Catheter policy does not include a process to prevent catheter drainage bag exposure to potently infectious settings. On 4/10/24, Surveyor reviewed R28's medical record. R28 was admitted to the facility on [DATE] with diagnoses including history of left hip fracture, diabetes, and urinary retention with a history of infections. R28's Minimum Data Set (MDS) assessment, dated 3/21/24, contained a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R28 had severe cognitive impairment. R28 had an activated Power of Attorney for Healthcare (POAHC). R28's physician orders included an order for Hiprex give 1 gram twice daily for 30 days for prevention of urinary tract infections (UTIs). On 4/10/24 at 9:23 AM, Surveyor observed R28 asleep in bed with the bed in the lowest position and a floor mat alongside the bed. Surveyor noted R28's catheter bag was resting on the floor mat next to the foot of the bed. There was not a barrier of protection between the bag and the floor mat. On 4/11/24 at 8:52 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who stated staff should use a cover for catheter drainage bags and uncovered bags should not be in contact with the floor. On 4/11/24 at 9:23 AM, Surveyor interviewed Registered Nurse (RN)-D who stated catheter bags shouldn't be on the floor. RN-D stated catheter drainage bags should contain a cloth cover to help prevent exposure of the bag for infection control as well as dignity. On 4/11/24 at 12:16 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A expects staff to keep catheter bags covered and off the floor.

Based on observation, staff interview, and record review, the facility did not ensure an injury of unknown origin was thoroughly investigated for 1 Resident (R) (R25) of 2 residents reviewed. The facility reported to the State Agency a concern involving a suspicious bruise on R25's face. The facility did not conduct a thorough investigation of the incident to rule out caregiver misconduct, did not re-educate staff on safety needs for R25 and did not update R25's care plan to help prevent the chance of further injury. Findings include: The facility's Abuse Prevention policy contained the following information: Good Shepherd shall immediately take steps to protect the resident involved and/or other susceptible care recipients .Good Shepherd will begin a thorough investigation, collecting information that corroborates or disproves the incident and document finding for each incident . On 4/17/23, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (an abnormality of water, electrolytes, vitamins, and other chemicals that adversely affect brain function) secondary to medication toxicity, Down's syndrome and Alzheimer's disease. R25's Minimum Data Set (MDS) assessment, dated 3/7/23, indicated R25 was rarely or never understood. R25's medical record contained guardianship documents, dated 7/1/19, that indicated R25's court-appointed guardian was responsible for R25's healthcare decisions. On 4/17/23 at 12:17 PM, Surveyor interviewed Legal Guardian (LG)-C who was visiting R25. LG-C indicated R25 had a bruise on R25's upper lip and R25's upper lip was swollen about a month ago and stated, They never told me what happened. Surveyor noted R25 had no visible bruising and had clean teeth with a slight underbite. On 4/18/23, Surveyor reviewed a facility-reported incident (FRI), dated 4/5/23, that stated, .Writer (Social Services Designee) believes the injury is consistent with the fact that (R25) may have bit the inside of (R25's) lip, or may have hit it (R25's) self and that there was no caregiver misconduct. On 4/18/23 at 8:39 AM, Surveyor observed ring-shaped assist bars positioned on the upper third of R25's bed and attached to both sides of the bed. On 4/18/23 at 8:41 AM, Surveyor observed R25 in a wheelchair in the common area. Surveyor noted R25 did not have any unusual movements of the arms, hands, lips or face. On 4/18/23 at 8:43 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who provided Surveyor with supporting documents related to the investigation of R25's bruised and swollen lip. NHA-A stated the documents provided were in addition to what was submitted to the Office of Caregiver Quality (OCQ). On 4/18/23, Surveyor reviewed the supporting documents which included an Investigation Report signed and dated by Director of Nursing (DON)-B and NHA-A on 4/4/23 that stated, .Injury likely occurred as an accidental bump during routine care .No new interventions at this time . On 4/18/23, Surveyor reviewed R25's plan of care did not mention the ring-shaped assist bars on R25's bed. R25's MDS assessment, dated 3/7/23, indicated R25 required extensive assistance of two staff for bed mobility. On 4/18/23 at 1:05 PM, Surveyor observed Certified Nursing Assistant (CNA)-D and CNA-E transfer R25 from wheelchair to bed with a full mechanical lift to provide incontinence care. During the observation, Surveyor noted when CNA-D and CNA-E repositioned R25 from side-to-side to adjust clothing and provide incontinence care, R25's head and face came close to the ring-shaped assist bars on each side of the bed. On 4/18/23 at 1:20 PM, Surveyor interviewed CNA-E who stated R25 was cooperative with cares. CNA-E stated R25 didn't use the ring-shaped assist bars to reposition and did not assist staff with repositioning. CNA-E verified R25 was dependent on staff for bed mobility and repositioning. CNA-E verified R25's face did not touch the ring-shaped assist bars during the care observation, but came close. On 4/18/23, Surveyor reviewed R25's medical record which did not contain a safety assessment or physician order for the ring-shaped assist bars. On 4/18/23 at 3:42 PM, Surveyor interviewed DON-B who stated the facility did not have a bed rail assist policy. DON-B indicated the facility did not do safety assessments for ring-shaped assist bars and stated, We do not consider them restraints. On 4/19/23 at 8:15 AM, Surveyor observed ring-shaped assist bars attached to both side of R25's bed as described above. On 4/19/23 at 10:38 AM, Surveyor interviewed DON-B. When questioned regarding the discrepancy between Social Services Designee's conclusion submitted to OCQ and DON-B's conclusion in the Investigation Report, DON-B stated, I didn't know we self-reported that (R25's swollen, bruised lip) until you asked for copies yesterday. When questioned what DON-B thought R25's face may have accidentally hit during the provision of care to cause bruising and swelling, DON-B stated possibly the bars on the mechanical lift used to transfer R25. DON-B verified R25 had a slight underbite which made it difficult for R25 to bite R25's upper lip accidentally. When questioned if R25 could have hit R25's face on the ring-shaped assist bars during cares, DON-B stated, I didn't think of that and verified it was possible. DON-B stated DON-B understood the investigation was not complete and interventions should have been put in place to help prevent re-injury, such as re-education of staff for safety during transfers/repositioning and/or removal of the ring-shaped assist bars. DON-B stated the ring-shaped assist bars would be removed from R25's bed immediately.

Based on observation, staff interview, and record review, the facility did not ensure staff performed proper hand hygiene for 2 Residents (R) (R16 and R25) of 4 residents observed during the provision of cares. Certified Nursing Assistant (CNA)-F and CNA-G did not consistently perform appropriate hand hygiene during the provision of perineal care for R16. CNA-E did not consistently perform appropriate hand hygiene during the provision of perineal care for R25. Findings include: The facility's Hand Hygiene policy, revised March 2023, contained the following information: This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: a. Before and after direct contact with residents; .f. Before moving from a contaminated body site to a clean body site during resident care; .j. After removing gloves .The use of gloves does not replace handwashing/hand hygiene. 1. On 4/17/23, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] with diagnoses to include diabetes mellitus and chronic kidney disease. On 4/17/23 at 11:53 AM, Surveyor observed CNA-F and CNA-G transfer R16 from wheelchair to bed and perform perineal care related to urinary incontinence. Following the provision of care, Surveyor observed CNA-F and CNA-G remove gloves. Without performing hand hygiene, CNA-F and CNA-G placed a clean brief on R16, repositioned R16 and adjusted R16's clothing. CNA-F and CNA-G then performed hand hygiene. Surveyor then observed CNA-F and CNA-G again reposition R16 for comfort and adjust R16's clothing and bedding. CNA-F then performed hand hygiene. Without performing hand hygiene, CNA-G moved a wheeled table, put the mechanical lift in the hallway and exited R16's room with a used disposable water cup. CNA-G then answered another resident's call light, turned off the call light, exited the room and entered the nourishment room. CNA-G put R16's used water cup in the trash, retrieved a new cup from the cupboard, and put ice in the cup with a scoop. CNA-G then filled the cup with water at the sink, obtained a straw, removed the wrapper and placed the straw in the cup. CNA-G then re-entered R16's room, put the cup on a table next to R16's bed, gave R16 the TV remote, and exited R16's room. CNA-G stopped in the hall to speak with a visitor who was visiting another resident. CNA-G stated to the visitor, I'll get (that resident's) meal tray. Surveyor stopped CNA-G further down the hall to interview CNA-G. On 4/17/23 at 12:09 PM, Surveyor interviewed CNA-G who verified staff should perform hand hygiene immediately following glove removal. CNA-G verified CNA-F and CNA-G did not perform hand hygiene immediately following glove removal after providing incontinence care. CNA-G also verified CNA-G should have performed hand hygiene prior to exiting R16's room. 2. On 4/18/23, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] with diagnoses to include Down's syndrome and Alzheimer's disease. On 4/18/23 at 1:05 PM, Surveyor observed CNA-D and CNA-E perform perineal care for R25 related to urinary incontinence. Following the provision of care, Surveyor observed CNA-E remove gloves and, without performing hand hygiene, don new gloves to continue with care. On 4/18/23 at 1:20 PM, Surveyor interviewed CNA-E who verified CNA-E should have performed hand hygiene between glove changes, but did not. On 4/19/23 at 10:47 AM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B expected staff to perform hand hygiene immediately following the removal of gloves, after providing care and upon exiting residents' rooms. Following a discussion of the observations listed above, DON-B verified staff did not follow the facility's expectations for hand hygiene.

Based on observation, interviews, and record review, the facility did not administer a pharmaceutical that met the need of 1 Resident (R) (R13) of 4 Residents observed during medication administration. Licensed Practical Nurse (LPN)-C did not obtain R13's blood pressure as ordered prior to administering [MEDICATION(S)] ([MEDICATION(S)]-valsartan; medication used for treatment of chronic heart failure) 24-26 milligrams (mg) tablet. Findings: On 5/3/22 at 7:53 AM, LPN-C administered R13's medications, including [MEDICATION(S)] 24-26 mg tablet. On 5/3/22 at approximately 9:30 AM, Surveyor reviewed R13's medical record which revealed the order: [MEDICATION(S)] 24-26 mg tablet, HOLD FOR LOW BP (blood pressure) standing order protocol < (less than) 90/50 1 tab (tablet) P.O. (by mouth) bid (twice a day) a.m. p.m. (cardiac failure) 2-21-22 (order date.) On 5/3/22 at 10:26 AM, Surveyor interviewed LPN-C who stated LPN-C did not obtain R13's blood pressure. LPN-C verified R13's blood pressure was not obtained prior to administering R13's [MEDICATION(S)]. LPN-C stated the electronic medical record did not prompt to enter a blood pressure, but the order did say to hold for low blood pressure. LPN-C stated night shift did pass on that R13's vitals were stable, but did not provide actual blood pressure. LPN-C immediately obtained R13's blood pressure after Surveyor brought order to LPN-C's attention. R13's blood pressure at 10:30 AM was 100/64. On 5/4/22 at 2:46 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B verified R13's order for [MEDICATION(S)] 24-26 mg tablet did state to hold if R13's blood pressure was less than 90/50 and that LPN-C should have obtained R13's blood pressure prior to administering [MEDICATION(S)].

Based on interview and record review, the facility did not ensure all residents were protected during an investigation after an allegation of neglect for 2 of 2 self-reported incidents to the State Agency (SA). Accused staff were not removed from caring for residents while investigations of abuse and neglect were occurring. Findings include: Facility policy titled, Investigation of Allegation of Abuse, Neglect, Misappropriation of Property or Injury of Unknown Source indicates: 5. Good Shepherd shall immediately take steps to protect the resident involved from further possible misconduct or retaliation. See Protection Policy and Procedure. The Facility Protection Policy and Procedure indicates: Good Shepherd shall take the necessary action within the limits of the law and corporation to protect residents, families and staff during an investigation of abuse, neglect, or misappropriation of property. Procedure: 1.Upon learning of an allegation of abuse, misappropriation of property, neglect, or other misconduct, Good Shepherd Services (GSS) shall immediately take action to prevent and protect those susceptible to further misconduct or retaliation. 2. If a GSS employee is the subject of an allegation, the Charge Nurse, Administrator, Social Service Director, Director of Nursing, Assistant Director of Nursing shall determine the most appropriate action. This may include: 1.Removal of the accused caregiver from the resident care area; 2. Suspension pending the outcome of the investigation; 3.Termination. Decisions will be made considering the seriousness of the act and the nature of the offense. On 5/4/22 at 10:40 AM, Surveyor reviewed the facility self reports and grievances as part of the Long Term Care Survey process. There were 2 facility self reported incidents. The first Facility Reported incident involved Resident (R14). R14 was admitted to the facility on [DATE] and had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicated that R14 was cognitively intact. On 5/2/22 at 1:00 PM, Surveyor interviewed R14 as part of the Long Term Care Survey process and noted the following related to R14's memory during interview. During this interview, R14 had a request and Surveyor requested R14 to place R14's call light on. The call light was answered within Minutes and when the Certified Nursing Assistant (CNA) came to ask R14 what R14 had wanted, R14 could not recall what R14 had pushed the call light for. Surveyor reminded R14 why R14 had pushed the call light. The facility utilizes a cover sheet to track the dates and investigations of FRIs (Facility Reported Incidents) to the SA. This cover sheet is titled: Complaint / Grievance Investigation Reportable to State and indicated the following: Incident Date / Time: 4/19/2022 at 4:09 AM (?) (noted per SW this was actually 4/20/22 at 4:09 AM) Date / Time Administrator Notified: 4/20/22 at 4:47 PM Date / Time Social Services Notified: 4/20/22 at 4:47 PM Date / Time initial reported to DQA immediately or (within 24 hours of discovery): 4/21/22 at 10:51:30 AM Date / Time 5 day investigation report filed with DQA: 4/22/22 at 6:01 PM Stapled to the back of this cover sheet was a handwritten note by Social Worker (SW-D) that indicated the following: On 4/20 after receiving message from (LPN) - (SW-D) went and briefly spoke with (R14). SW-D asked if (R14) had any concerns regarding any staff that had worked the last 24 hours. (R14) own person told me (R14) had no concerns with anyone - writer looked at schedule to see who was assigned to the wing. (CNA-F) was on. (CNA-F) was assigned to work but not on (R14's) unit. CNA-F was assigned to work another unit pending the results of the investigation 4/21/22 - Full investigation was turned over to (Activity Director) to complete. On 5/4/22, Surveyor reviewed the 24 hour report paperwork that was submitted to the State Agency (SA). Under the section labeled: 'Name what steps the entity took upon learning of the incident to protect the affected person(s) and others from further misconduct':, it stated: The CNA was removed from caring for the resident pending investigation. On 5/4/22 at 11:18 AM, Surveyor interviewed SW-D who indicated that SW-D submits the reports to the state agency. SW-D indicated that SW-D was notified from nursing staff that R14's family had called and indicated that earlier that morning (night shift), R14 had put on call light to use the bathroom and was told that R14 would need to wait until the next shift to go to the bathroom. SW-D indicated to Surveyor that SW-D had immediately contacted Nursing Home Administrator (NHA-A) and then went to interview R14 based on the allegation of neglect. SW-D indicated R14 could not recall anyone telling R14 could not use the restroom. R14 did indicate that at shift change R14 does need to wait sometimes but understood. SW-D indicated that SW-D reviewed the schedule to determine it was Certified Nursing Assistant (CNA-F) that was working with R14 at the time of the alleged incident. SW-D noted that CNA-F was scheduled to work that night on a different unit. SW-D indicated that NHA-A indicated that CNA-F could work since it was on a different unit. SW-D confirmed CNA-F worked with the residents on the other wing the following night shift (10pm - 6am) before the investigation was completed. SW-D further indicated that it depends on the allegation whether a CNA is pulled completely from resident care. SW-D indicated there are only 2 CNAs on night shift and confirmed that CNA-F was probably not supervised while caring for other residents while the investigation was being completed. SW-D indicated there have been instances where a staff was pulled completely from resident care, such as if a resident would indicate they were hit or pinched. But because the allegation came from R14's family member and R-14 had no concerns during SW-D initial interview, the staff person did work per NHA-A direction. SW-D indicated that the activity director completed the investigation the following day and CNA-F was interviewed the following morning 4/21/22 after CNA-Fs night shift. Surveyor reviewed the investigative write up that was submitted to the SA which showed that call light logs were reviewed with CNA-F. Writer reviewed call log with CNA-F, (CNA-F) response is noted below: 4:09 a.m. - Pressed light for (R14's ) roommate 4:15 a.m. - R14 went to bathroom 5:06 a.m. - Needed bathroom again - CNA-F stated she could put R14 on the toilet but R14 would need to wait a bit as R14 needed to assist other residents that were trying to exit their beds. The other CNA was unable to assist as the other CNA was helping other residents. 5:33 a.m. - Needed bathroom again - CNA-F stated CNA-F could put R14 on the toilet but R14 would need to wait a bit as CNA-F needed to assist other residents that were trying to exit their beds. The other CNA was unable to assist as the other CNA was helping other residents. 5:45 a.m. - Needed bathroom again - CNA-F stated she could put R14 on the toilet but CNA-F would need to wait a bit as she needed to assist other residents that were trying to exit their beds. The other CNA was unable to assist as the other CNA was helping other residents. CNA-F informed R14 that the next shift would be able to assist shortly. Based on interview above with SW-D, this review with CNA-F occurred after the facility was aware of the investigation and after CNA-F worked the night shift. On 5/04/22 at 11:30AM, Surveyor interviewed NHA-A who indicated this was a very different situation as the allegation did not come from the resident and R14 had no concern on initial interview. NHA-A indicated that each situation is different. NHA-A indicated R14 had been with family a good portion of the day at the facility and did not tell staff or any family of the situation. The facility did not hear about it until the late afternoon. R14's attitude and demeanor was good throughout the day. NHA-A indicated when the report came in NHA-A gathered the team via conference call to discuss the allegation and determined this was an ongoing issue with R14 who tended to want to get up around shift change. NHA-A indicated NHA-A did make the call to allow CNA-A to work the shift that evening based on the information NHA-A had which was: There were not any other previous concerns with CNA-F, CNA-F was working on a different wing, NHA-A knew the family member personally, NHA-A took into account R14 had been with family all day, R14 is R14's own person and had not mentioned this to anyone else, and the comment from the nurse's during the conference call that R14 always wants to get up at shift change which is an issue. NHA-A indicated another part of the equation was staffing and that NHA-A may have not been able to replace CNA-F for that night's shift which would have been neglectful of other residents. NHA-A indicated that CNA-F was working another unit and if NHA-A truly thought that other residents were in harms way, NHA-A would have pulled CNA-F. On 5/4/22, Surveyor reviewed am additional facility reported incident submitted to the SA related to R4 making a complaint that the day shift CNA was Mean. On the 24 report submitted to the SA under, 'Name what steps the entity took upon learning of the incident to protect the affected person(s) and others from further misconduct':, it stated: The CNA was removed from caring for the resident pending investigation. On 5/04/22 at 12:24 PM, Surveyor interviewed SW-D who could not recall if CNA-E was removed from shift or how that worked. On 5/04/22 at 12:28 PM, Surveyor interviewed CNA-E who recalled the incident and indicated CNA-E kept working and no one talked with CNA-E about not working when that happened. On 5/04/22 at 1:56 PM, Interview with NHA-A indicated NHA-A could not recall if CNA-E was pulled from caring for residents, but indicated the investigation did not take long to complete the interviews and CNA-E may have been giving someone a shower. NHA-A asked if staff should sit on a bench while completing the investigation. On 5/4/22, Surveyor reviewed the facility cover sheet, Complaint / Grievance Investigation Reportable to State which showed that the facility was notified of the allegation on 2/7/22 at 8:50 AM and the final 5 day report was submitted to the state on 2/7/22 at 1:31 PM.

Based on record review and staff interview, the facility did not ensure an allegation of abuse was reported in a timely manner for 1 Resident (R) (R4) of 1 resident. R4 reported an allegation of abuse on 10/15/21. The allegation of abuse was not reported to NHA (Nursing Home Administrator)-A or the State Agency in a timely manner. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy states: It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property . An owner, licensee, Administrator, Licensed Nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator. The Nursing Home Administrator or designee will report abuse to the State Agency per state and federal requirements. Procedure: Internal Reporting: a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator. b. The Administrator will involve key leadership personnel as necessary to assist with reporting . External Reporting: a. Initial reporting of allegations: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. A follow-up investigation will be submitted to the State Agency within five working days. On 10/26/21, the Surveyor reviewed a facility self report. The five day investigation, submitted to the State Agency on 10/18/21 by SSD (Social Services Director)-D, stated R4 told staff on the morning of 10/15/21 that NOC (night) shift CNA (Certified Nursing Assistant)-C whispered in R4's ear, If you get up, I hope you fall. The report stated R4 was teary-eyed and afraid to say anything due to retaliation from staff. CNA-C was suspended pending the outcome of the investigation. Interviews were conducted with other residents. CNA-C was interviewed and subsequently terminated. The Surveyor noted the self report did not contain an initial report that was submitted to the State Agency as soon as possible but not to exceed twenty four hours after discovery of the allegation. The investigation contained a statement from RN (Registered Nurse)-E that indicated RN-E spoke with R4 and R4's spouse on 10/15/21 after CNA-F notified RN-E at 2:00 PM that R4 reported an allegation of abuse earlier that morning. RN-E stated R4 asked CNA-C at 5:20 AM to help R4 use the bathroom and get dressed for the day. R4 stated R4's request was denied multiple times before CNA-C whispered in R4's ear, I hope you fall. Following the incident, R4 called R4's spouse due to fear of CNA-C. The investigation contained a statement from DON (Director of Nursing)-B that indicated DON-B interviewed CNA-C on 10/15/21. CNA-C stated R4 twice activated R4's call light and asked to get out of bed. CNA-C stated CNA-C denied R4's request both times because it was too early to get up. CNA-C also stated CNA-C told R4 in a joking manner,If you fall, I won't help you up. The investigation contained a statement that indicated SSD-D interviewed R4 on the morning of 10/18/21. The Misconduct Incident Report form indicated the allegation of abuse was initially submitted to the State Agency on 10/18/21 at 12:54 PM. On 10/26/21 at 12:40 PM, the Surveyor interviewed SSD-D regarding the twenty-four hour report. SSD-D stated SSD-D was not in work status on 10/15/21, but received a text from NHA-A on 10/17/21 that there was a reportable for Monday (10/18/21) AM. SSD-D stated the allegation of abuse wasn't reported to RN-E until approximately 2:00 PM on 10/15/21 and verified the allegation of abuse was not reported to the State Agency within twenty-four hours of discovery. On 10/26/21 at 12:45 PM, the Surveyor interviewed CNA-F regarding the allegation of abuse. CNA-F stated R4 seemed distraught and out of sorts on the morning of 10/15/21 when CNA-F assisted R4 with cares between 6:30 and 7:00 AM. CNA-F stated, (R4) said (CNA-C) told (R4) (CNA-C) wished (R4) would fall. (R4) said (R4) was walking in the hallway (earlier in the shift) and knew (R4) shouldn't have (done that). CNA-F told R4 that CNA-F would tell RN-E; however, the morning was crazy and CNA-F did not report the allegation to RN-E until approximately 1:00 PM. On 10/26/21 at 12:57 PM, the Surveyor interviewed AD (Activities Director)-G regarding the allegation of abuse. AD-G verified AD-G filled in for SSD-D when SSD-D was not in work status. AD-G stated AD-G was informed of the allegation of abuse on 10/15/21 and conducted interviews with R4 as well as other residents. AD-G verified AD-G did not report the allegation of abuse to the State Agency on 10/15/21. On 10/26/21 at 2:45 PM, the Surveyor interviewed NHA-A regarding the allegation of abuse. NHA-A verified the allegation of abuse was not reported to the State Agency in a timely manner on 10/15/21. NHA-A stated NHA-A thought the initial report was submitted on 10/15/21; however, later learned the report was not submitted.