Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nursing And Rehabilitation Center At Good Shepherd during CMS and state inspections, most recent first.
An LPN administered medications through a resident’s PEG tube while wearing gloves but not a gown, despite EBP signage and PPE being present at the doorway and the resident being identified for EBP related to the feeding tube. The resident had stroke, dysphagia, and severe cognitive impairment, and the care plan required gown and glove use during high-contact care. The LPN said he was not aware of special precautions, while the DON and Administrator confirmed gowning and gloving were expected for PEG tube medication administration.
The facility failed to conduct a comprehensive assessment to determine necessary resources for resident care, lacking details on the physical environment, staffing plans, and contingency plans. The assessment did not evaluate the care required by residents using evidence-based methods, nor did it address staffing needs or competency-based approaches. An interview with the Administrator confirmed the assessment's incompleteness.
The facility failed to ensure call lights were within reach for five residents, as observed during a survey. Call lights were found tied to handrails, hanging above the floor, or placed on nightstands, making them inaccessible. Staff confirmed the importance of having call lights accessible, acknowledging potential harm if residents couldn't call for help. Despite in-service training, the facility lacked a specific policy on call lights, contributing to the deficiency.
The facility failed to maintain a clean and sanitary environment in the shower room on the 500 Hall. Observations revealed scrape marks, brownish/black residue, and stains on the walls, with cluttered supplies in the sink area. Interviews with the DON and Housekeeping Supervisor confirmed the need for cleaning, but subsequent checks showed incomplete cleaning efforts.
The facility failed to accurately complete MDS assessments for two residents. One resident's MDS did not reflect a fall with a major injury, despite evidence of a significant fracture. Another resident's MDS incorrectly indicated they were not on antidepressants, contrary to their care plan and medication orders. The LTC MDS Coordinator acknowledged the errors, highlighting a need for further training.
The facility failed to update care plans for residents, leading to deficiencies in comprehensive care planning. A resident with dementia experienced multiple falls without new interventions, while another resident's care plan was not updated due to staff absence. A third resident's fall with major injury was not documented, and inaccuracies were found in the care plans of two other residents regarding pressure ulcers and anticoagulant therapy.
The facility did not serve meals according to the planned menu for residents on pureed diets. Residents were served only 4 ounces of pureed pizza instead of the planned 8 ounces, and regular oatmeal instead of pureed oatmeal. The Dietary Manager confirmed these errors.
The facility failed to ensure proper food storage and handling, with expired and improperly stored items found in the refrigerator and freezer. A dietary aide did not follow hygiene protocols, contaminating clean dishes. Hot food items were not maintained at the required temperature, posing a risk of foodborne illness.
A resident with Alzheimer's disease required assistance with personal hygiene and eating. Observations showed the resident had food particles on their clothing and bed linens, indicating a lack of timely cleaning. Interviews with staff confirmed the need for assistance, which was not provided, violating the facility's policy on resident rights.
A resident with acute respiratory failure was not provided with proper oxygen therapy as the oxygen concentrator was set at incorrect rates and was not maintained as per schedule. The equipment was found dirty, and the oxygen tubing and humidified water bottle were outdated. An LPN confirmed the discrepancies, and the DON verified the incorrect oxygen rate, although the resident's oxygen saturation was stable.
Failure to Follow EBP During PEG Tube Medication Administration
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were followed during medication administration through a PEG tube for one resident. The resident had diagnoses including stroke, dysphagia, and heart attack, and the quarterly MDS indicated severe cognitive impairment and the presence of a feeding tube. The care plan, revised 07/01/2024, identified the resident as being on EBP related to the PEG tube, with gown and glove use required during high contact resident care including feeding tubes. During an observation on 01/14/2026, an LPN prepared and administered medications through the resident’s PEG tube while wearing gloves but not a gown, despite EBP signage and PPE being present inside the doorway and the resident’s name being marked in orange outside the room. The LPN turned off the feeding pump, disconnected the tube, flushed it with water, administered the medication solution, flushed again, and reconnected the tube. In interview, the LPN stated he was not aware of any special precautions for the resident and said he did not see anything on the orders. The DON confirmed staff should gown and glove when administering medications through a feeding tube, and the Administrator stated staff were expected to follow EBP and that the LPN did not put on a gown during the medication pass.
Incomplete Facility Assessment
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment, dated November 2017, lacked critical information required to ensure the allocation of necessary care and resources for the resident population. Specifically, it did not include details about the physical environment, equipment, and services needed to care for the residents. Additionally, the assessment failed to evaluate the care required by the resident population using evidence-based, data-driven methods, which are essential for understanding the intensity of care and services needed. Furthermore, the facility assessment did not address staffing plans, including the evaluation of the overall number of staff required to meet residents' needs based on the facility census. It also omitted a competency-based skill set approach for staffing decisions, a plan for recruiting and retaining adequately trained medical personnel, and an assessment of the facility's resources, including buildings, equipment, and services. The assessment lacked information on health information technology resources and a contingency plan for events impacting resident care. An interview with the Administrator confirmed that the facility assessment was incomplete, indicating a failure to ensure the necessary care and resources were allocated to meet the residents' needs.
Call Lights Out of Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for five residents, as observed during a survey. On multiple occasions, call lights were found to be out of reach for residents, either tied to handrails, hanging above the floor, or placed on nightstands, making them inaccessible. This was observed for Residents #13, #24, #51, #80, and #96, indicating a pattern of neglect in ensuring residents could easily access their call lights in case of need or emergency. Interviews with staff, including CNAs and an LPN, confirmed that call lights should be within reach of residents to allow them to signal for assistance. Staff acknowledged the importance of this practice, noting that failure to have call lights accessible could result in harm if residents were unable to call for help during an emergency. Despite in-service training provided to staff on multiple occasions, the facility did not have a specific policy regarding call lights, contributing to the deficiency.
Failure to Maintain Clean Shower Room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the shower room on the 500 Hall, as observed during a survey. The facility's policy on Resident Rights, revised in 2016, mandates that residents receive care in a safe and clean environment. However, during an observation, the shower room was found to have large scrape marks on the stalls, an unidentified brownish/black residue along the edges where the floor meets the walls, and a brownish substance stain on the tiled walls. Additionally, the sink area was cluttered with supplies, indicating a lack of cleanliness and organization. Interviews with the Director of Nursing (DON) and the Housekeeping Supervisor confirmed the presence of the black/brown substance along the edges of the shower stalls and the brown substances splattered on the walls. Both acknowledged that the shower room required cleaning. Despite assurances that the room would be cleaned, a subsequent observation revealed that while some areas had been covered with new white material, the brownish-black residue and substances on the walls remained, indicating that the cleaning was incomplete.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were accurately completed for two residents. For Resident #88, the MDS inaccurately reported a fall with no major injury, despite evidence of a fall resulting in a significant injury, specifically a closed fracture of the proximal end of the left tibia. The care plan for Resident #88 indicated a history of falls and an increased risk due to gait instability and weakness, yet it lacked interventions to prevent reoccurrence. The incident report and hospital records confirmed the major injury, but this was not reflected in the MDS or the facility roster matrix. For Resident #30, the MDS inaccurately indicated that the resident was not taking an antidepressant, despite the Order Summary Report and care plan showing that an antidepressant had been prescribed and was in use. The LTC MDS Coordinator acknowledged the errors in the MDS assessments, citing a need for further training. The Director of Nursing and the Administrator confirmed the inaccuracies and the necessity for the MDS to reflect accurate resident information.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans for several residents, leading to deficiencies in comprehensive care planning. Resident #7, who had a history of dementia and cognitive impairment, experienced multiple falls without any new interventions being implemented. Despite being identified as a high risk for falls, the care plan had not been updated with new strategies since 2018, and there was a lack of thorough investigation or documentation following the falls. Resident #36, who had a history of stroke and cognitive impairment, also experienced falls without appropriate updates to their care plan. Although interventions were initially developed, the care plan was not revised to reflect the most recent fall due to the LTC MDS Coordinator being on vacation. This oversight resulted in a lack of timely and effective fall prevention measures. Resident #91, who was cognitively intact but had a history of stroke and paralysis, experienced a fall with a major injury. The care plan was not updated promptly, and there was a lack of documentation regarding the fall. Additionally, Resident #72's care plan did not accurately reflect the current status of their pressure ulcers, and Resident #30's care plan inaccurately included anticoagulant therapy that had already been completed. These deficiencies highlight the facility's failure to maintain accurate and up-to-date care plans for residents, potentially compromising their safety and well-being.
Failure to Serve Meals According to Planned Menu for Pureed Diets
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu, resulting in nutritionally imbalanced meals for residents on pureed diets during two observed meals. On September 30, 2024, the noon meal menu specified that residents on pureed diets were to receive 8 ounces of pureed pizza, which was their choice for the meal of the month. However, Dietary staff used a #8 scoop, equivalent to 4 ounces, to serve the pureed pizza, providing only half of the required portion. Additionally, on October 1, 2024, the breakfast menu indicated that residents on pureed diets were to receive pureed hot cereal, but they were served regular oatmeal instead. The Dietary Manager confirmed the error, and the staff member acknowledged the mistake in serving regular oatmeal instead of pureed oatmeal.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to adhere to proper food storage and handling protocols, which could potentially lead to foodborne illnesses. Observations revealed that an opened bottle of Worcestershire sauce was not refrigerated as per manufacturer instructions. Additionally, expired dairy products and undated, unlabeled food items were found in the refrigerator and freezer, including a carton of nutritional drink and a container of nectar thickened apple juice past their expiration dates. An opened and undated box of homemade ice cream was also found discolored and with ice cycles, indicating improper storage. Furthermore, dietary staff did not follow proper hygiene practices. A dietary aide was observed contaminating his gloves while handling dirty dishes and then proceeding to handle clean dishes without washing his hands. Additionally, hot food items on the steam table were not maintained at the required temperature of 135 degrees Fahrenheit or above, with items such as mashed potatoes, pureed vegetable blend, gravy, and cheese sticks all recorded at temperatures below the standard, posing a risk of foodborne illness to residents.
Failure to Maintain Resident Dignity and Cleanliness
Penalty
Summary
The facility failed to uphold the dignity of a resident by not providing adequate personal cleanliness after meals. The resident, who was admitted with Alzheimer's disease and chronic pain, required assistance with personal hygiene and eating. Observations revealed that the resident had oatmeal and food particles on their clothing and bed linens on multiple occasions, indicating a lack of timely cleaning and assistance from the staff. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the resident needed assistance with cleaning after meals and that the linens should have been changed. The facility's policy on resident rights emphasized the importance of providing adequate nursing care and maintaining personal cleanliness, which was not adhered to in this case.
Deficiency in Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident requiring oxygen therapy. The resident, admitted with acute respiratory failure and hypoxia, had a physician's order for oxygen at 3 liters per minute (LPM) via nasal cannula. However, observations revealed that the oxygen concentrator was set at incorrect rates of 2.5 LPM and later 1.5 LPM, instead of the prescribed 3 LPM. Additionally, the oxygen concentrator was found to be dirty with undetermined particles and dust, and the oxygen tubing and humidified water bottle were not replaced or dated as required, with dates showing from nearly two months prior. Interviews with the LPN confirmed the discrepancies in the oxygen rate and the cleanliness of the equipment. The LPN acknowledged that the oxygen rate was not set correctly and that the equipment had not been maintained according to the facility's schedule. The DON also confirmed the incorrect oxygen rate and checked the resident's pulse oximetry, which was at 98 percent. Despite the resident's stable oxygen saturation, the facility's failure to adhere to the prescribed oxygen rate and maintenance schedule constituted a deficiency in providing safe and appropriate respiratory care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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