Good Shepherd Village

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF804Jun 30, 2026

  Based on observations and resident and staff interviews, the facility failed to ensure meals were palatable and served at proper temperature. This had the potential to affect all 59 residents who receive their meals from the kitchen. Findings include:Interview on 06/22/26 at 3:47 P.M. with Resident #7 reported the food was terrible and most of the time it was cold, had no taste, and meats were tough.Review of the dinner menu for 06/24/26 revealed dinner was a chicken ranch wrap, side salad, vegetable soup, and a slice of yellow cake for dessert.Observations of holding temperatures at the start of dinner service on 06/24/26 at 5:07 P.M. […]

• No harm, potential for more than minimal, widespreadF880Jun 30, 2026

  Based on observation, record review, personnel file review, staff interview, and policy review, the facility failed to ensure staff completed proper hand hygiene during tracheostomy care and failed to ensure tuberculosis (TB) Mantoux screenings were completed according to the facility's TB Risk Assessment. This affected Resident #5 and had the potential to affect all 59 residents residing in the facility.Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 11/19/25. Diagnoses included non-traumatic intracranial hemorrhage and tracheostomy status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was unable to complete the Brief Interview for Mental Status (BIMS) assessment. […]

• No harm, potential for more than minimal, widespreadF803May 1, 2025

  Based on observations, staff and resident interviews, medical record record review, meals substitute log review, menu review, diet tech audit review, and policy review, the facility failed to follow meal tickets and scheduled menu and an updated/ accurate substitution log. This affected two (#16 and #30) of three residents reviewed for nutrition with potential to affect all residents who receive meals from the dining room. Facility identified all facility residents eat food from the kitchen. The facility census was 65. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 08/13/24. Diagnoses included pneumonia, malnutrition, hemiplegia, heart failure, vascular disease, and respiratory failure. […]

• No harm, potential for more than minimal, widespreadF804May 1, 2025

  Based on an observation, staff and resident interviews, medical record review, diet tech audit review, and policy review, the facility failed to ensure food had a palatable taste and was served at an appetizing temperature. This affected four (#1, #16, #30, and #367) of six residents reviewed for dietary needs. The facility identified all residents eat food from the kitchen. The facility census was 65. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 08/13/24. Diagnoses included pneumonia, malnutrition, hemiplegia, heart failure, vascular disease, and respiratory failure. […]

• No harm, potential for more than minimal, widespreadF812May 1, 2025

  Based on observation, staff interviews and policy review, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all 65 residents. The facility census was 65. Findings include: Observation of the walk in freezer on 04/28/25 at 8:49 A.M. revealed frozen waffles in a bag without a date. Ice was observed on the tops of boxes of Mighty Shakes and B/C Topping that were stored under the freezer condenser. Interview with the Kitchen Manger (KM) #237 confirmed that the frozen waffles did not have a date. KM #237 confirmed that the condenser appeared to be leaking and creating a build up of ice on the boxes stored below. Observation on 04/28/25 at 8:54 A.M. […]