Lutheran Home of the Good Shepherd

In the surveyor’s words

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

• Immediate jeopardy, isolatedF880Jul 10, 2024

  Based on observation, review of manufacturer's instructions, and staff interview, the facility failed to follow infection control standards for 3 of 3 residents (Resident #7, #8, and #41) observed during blood glucose testing. Failure to properly disinfect glucometers may result in the spread of bloodborne pathogens between residents. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 07/08/24 at 5:55 p.m. The IJ resulted from a staff member improperly cleaning a glucometer and attempting to use it with another resident. This finding placed residents in immediate danger due to the potential for exposure to bloodborne pathogens. […]

• Actual harm, isolatedF689Aug 28, 2025

  This REQUIREMENT is NOT MET as evidenced by:Based on record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #36) who was injured during van transport. Failure to provide the appropriate level of assistance ensuring Resident #36's extremities remained within the frame of the wheelchair/were supported while loading her into the van, resulted in a major injury to her left foot.Findings include:Review of the facility policy titled Safe Lift and/or Ramp Usage in the Vans occurred on 08/28/25. This policy, revised 2022, stated, . Open doors and Lower lift, Load resident with brakes on, Transfer resident into placement . […]

• Actual harm, isolatedF600Jun 4, 2025

  Based on review of a facility reported incident (FRI) investigation, record review, review of facility policy review, and staff interview, the facility failed to ensure residents have the right to remain free from possible physical abuse/neglect for 1 of 1 sampled resident (Resident #3) with a fracture or unknown source. Failure to provide necessary service to protect residents from physical harm resulted in Resident #3 sustaining a fracture from an unknown source. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following discovery of the incident. Findings include: The surveyor determined a deficient practice existed on 05/26/25. […]

• No harm, potential for more than minimal, isolatedF658Aug 28, 2025

  Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure staff followed professional standards of practice for 2 of 4 sampled residents (Resident #6 and #36) observed during medication administration. Failure to prime insulin pens correctly and failure to administer medications at the scheduled times may impede the therapeutic effectiveness of the medications.Findings include:The facility failed to provide a policy on medication administration and documentation.Review of the facility policy titled Insulin Pen Use occurred on 08/27/25. This policy, dated 2021, stated, . prime pen with 2 units of insulin pointing the pen with the needle upwards. […]

• No harm, potential for more than minimal, isolatedF880Aug 28, 2025

  Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 14 sampled residents (Resident #3 and #6) observed during cares. Failure to practice infection control standards related to hand hygiene and glove use has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Personal Protective Equipment occurred on 08/28/25. This policy, revised July 2022, stated, . Gloves . Perform hand hygiene before donning [applying] gloves and after removal. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another . -Observation on 08/25/25 at 1:15 p.m. […]