The Good Shepherd Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at The Good Shepherd Health and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 27, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, hospital documentation review, resident and staff interview, review of a personnel file, review of a disciplinary action document, review of an investigation, policy review, and review of facility initiated corrective action, the facility failed to ensure appropriate care and assistance was provided to prevent a resident fall. This resulted in actual harm when Resident #104 was transferred by a mechanical (Hoyer) lift using only one staff member to assist, and subsequently fell , causing a facial laceration requiring sutures and a fractured right leg which required hospitalization and surgical intervention. […]

• No harm, potential for more than minimal, widespreadF880Aug 13, 2026

  Based on observation, staff interviews, record reviews, facility policy reviews, and review of manufacturer instructions, the facility failed to maintain infection control standards related to proper hand hygiene, use of Enhanced Barrier Precautions (EBP), and during cleansing of resident-shared glucometers. This affected three residents (#7, #64, and #67) of 11 residents reviewed for infection control and had the potential to affect all residents residing in the facility. The facility census was 118. Findings include: 1. Resident #7 was admitted to the facility on [DATE] and had diagnoses that included Parkinson's disease, obstructive uropathy, and dementia. […]

• No harm, potential for more than minimal, widespreadF761Mar 3, 2022

  Based on observations, staff interviews, and policy review, the facility failed to remove expired medications from the medications carts and medication storage rooms. This affected three of six medication carts and two of three medication storage rooms. This had the potential to affect all 92 residents residing in the facility. Findings include: Observation of Windsor medication cart on 03/01/22 at 7:55 A.M. revealed a bottle of CoQ 10 was found with an expiration date of 01/2022 and a bottle of aspirin 325 milligrams (mg) was located in the cart with an expiration date of 11/2021. Observation of the Windsor [NAME] Hall medication room on 03/01/22 at 8:22 A.M. […]

• No harm, potential for more than minimal, patternF761Aug 13, 2026

  Based on observation, interview, record review and facility policy review, the facility failed to properly store and secure medications. This affected eight residents (#21, #32, #40, #67, #72, #76, #98, and #129) and had the potential to affect the residents residing on the Continuing Care Front Hall, Continuing Care Back Hall, and Memory Care units. The facility census was 118. Findings include: 1.Observation on 08/10/26 at 4:14 P.M. of medication storage with Registered Nurse (RN) Supervisor #375 of the Continuing Care medication storage refrigerator revealed there were two applesauce containers and four cans of beer sitting next to several Haldol (an antipsychotic medication) injections, insulin pens and rectal suppositories. […]

• No harm, potential for more than minimal, patternF881Jul 18, 2024

  Based on infection control tracking, staff interview, and policy review, the facility failed to follow antibiotic stewardship practices in prescribing antimicrobials. This affected 17 (Resident #6, #7, #9, #21, #27, #40, #51, #55, #69, #57, #70, #73, #76, #78, #83, #101, and #107) of 57 resident entries for antimicrobial treatments initiated in May and June 2024. The facility census was 119. Findings include: Review of infection control tracking for May 2024 revealed there were 32 antimicrobial (antibiotic and antifungal) treatments tracked for the month. The treatments were prescribed from a variety of sources that include from the hospital upon admission, emergency room prescribers, hospice prescribers, and the facility's prescribers. […]