Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Golden Good Shepherd Home during CMS and state inspections, most recent first.
A resident was mistakenly given another resident's medications due to a verification error, leading to severe adverse effects and emergency medical intervention. The nurse only verified the first name, resulting in the administration of a toxic combination of drugs. The resident experienced lethargy, arrhythmia, and respiratory depression, necessitating emergency room treatment.
The facility failed to use an effective sanitation solution in the kitchen, affecting all 35 residents. A Dietary Cook used a cloth soaked in a weak bleach solution to clean a food thermometer and a preparation table. The solution was only ten PPM, below the required 50-100 PPM for effective sanitation. The Dietary Manager confirmed the deficiency, noting the unavailability of alcohol wipes normally used for sanitizing.
A resident with multiple health conditions, including urinary retention, was observed with an uncovered urinary catheter bag attached to their walker, visible from the hallway. This occurred over several days, and the facility's Director of Nursing confirmed that the bag should have been covered to maintain the resident's dignity, as per facility protocol.
A resident with severe cognitive impairment and multiple health conditions was unable to reach their call light, which was found draped across a bedside table. The facility's policy requires call lights to be within reach and placed on the bed. The DON confirmed that call lights should always be accessible to residents.
A facility failed to update a resident's care plan to reflect their change from Full Code to DNR status, despite having a POLST form and Physician's Order indicating DNR. The Social Service Director admitted the oversight, leading to a discrepancy between the resident's documented treatment preferences and their care plan.
The facility failed to implement restorative range of motion (ROM) programs for two residents with functional limitations. Both residents, who were cognitively intact, expressed a desire for ROM exercises but did not receive any therapy or restorative programs. The facility's care plans did not address their ROM limitations, and the Director of Nursing acknowledged the absence of a restorative nurse or CNA. The facility's policies on restorative care were not followed, resulting in the deficiency.
A facility failed to document daily weights for a resident with CHF, as ordered by the physician. The resident, with a history of edema and dehydration, missed multiple scheduled weights over several months. Interviews revealed that CNAs, including agency staff unfamiliar with routines, were responsible for weights. The DON confirmed the lack of documentation and physician notification, contrary to facility policy.
A resident with Dementia was prescribed Risperidone without documented diagnosis or target behaviors to justify its use. Despite being calm and cooperative, the facility did not attempt a gradual dose reduction or conduct necessary assessments. The facility's policy on psychotropic medications was not followed, as there was no documented rationale for the medication, nor were regular reviews conducted.
Resident Receives Wrong Medication Due to Identity Verification Failure
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in a serious incident involving a resident, referred to as R4. R4 was mistakenly given another resident's medications due to a mix-up caused by both residents having the same first name. The error occurred when the nurse, identified as V12, only verified the first name of the resident before administering the medication. This led to R4 ingesting a toxic amount of medication, which included a combination of drugs such as Mirtazapine, Atorvastatin, and Clonazepam, among others. Following the administration of the wrong medication, R4 experienced severe adverse effects, including increased lethargy, arrhythmia, sedation, and respiratory depression. Initially, the Director of Nursing, V2, documented that R4 was alert and oriented, and there was no immediate need to send R4 to the emergency room. However, later that evening, R4's oxygen saturation levels dropped significantly, prompting a call to the on-call physician, who then ordered R4 to be sent to the emergency room. In the emergency department, R4 was treated for toxic ingestion and showed improvement after receiving intravenous fluids. The incident highlights a critical lapse in the facility's medication administration process, as outlined in their policies. The policies require verification of the resident's identity through multiple methods, including checking identification bands and photographs, and verifying with other facility personnel if necessary. Additionally, the policy mandates checking the medication label three times to ensure the right resident, medication, dosage, time, and method of administration. The failure to adhere to these procedures resulted in a significant medication error that required emergency medical intervention for R4.
Ineffective Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to ensure the use of an effective sanitation solution in the kitchen, which has the potential to affect all 35 residents residing in the facility. During an observation, the Dietary Cook used a cloth soaked in a quaternary (bleach) sanitation bucket to clean a food thermometer between taking temperatures of various hot and cold food items. The same cloth was then used to wipe down a metal food preparation table. The concentration of the sanitation solution was tested and found to be only ten PPM, whereas the required concentration for effective sanitation is between 50-100 PPM. The Dietary Manager confirmed that the sanitation solution was not effective at ten PPM and acknowledged that alcohol wipes, which are normally used for sanitizing the thermometer, were unavailable. The facility's policies require that all equipment, food contact surfaces, and utensils be cleaned and sanitized using heat or chemical sanitizing solutions of appropriate concentration. The failure to maintain the correct concentration of the sanitation solution and the improper use of the cloth for multiple purposes led to the deficiency.
Failure to Cover Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident by not covering their urinary catheter bag with a privacy bag. The resident, who was admitted with multiple diagnoses including cerebral infarction, hemiplegia, chronic kidney disease, and urinary retention, was observed on multiple occasions with an uncovered urinary catheter bag attached to their walker. This bag, which was half full of urine, was visible from the hallway, compromising the resident's dignity and privacy. The observations were made over several days, with the resident consistently found sitting in their recliner with the catheter bag exposed. The Director of Nursing confirmed that the facility's protocol requires urinary catheter bags to be covered with a privacy bag, acknowledging that this was not done for the resident in question. The facility's Resident Rights Booklet emphasizes the importance of treating residents with dignity and respect, which was not upheld in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of residents. The resident, who was admitted with multiple diagnoses including Dementia, Urinary Tract Infection, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease, was found to have severe cognitive impairment with a BIMS score of 3. During an observation, the resident was unable to locate the call light, which was found draped across a bedside table and not within reach. The Director of Nursing confirmed that all residents should have their call lights within reach at all times. The facility's call light policy emphasizes the importance of positioning the call light conveniently for residents and ensuring it is placed on the bed, not on the floor or bedside table.
Failure to Update Resident's DNR Status in Care Plan
Penalty
Summary
The facility failed to ensure that a resident's Physician Order and Practitioner Order for Life-Sustaining Treatment (POLST) DNR (Do Not Resuscitate) code status was accurately updated in the resident's care plan. This deficiency was identified for one of the twelve residents reviewed for Advanced Directives. The resident, referred to as R35, had a POLST form and a Physician's Order both indicating a DNR status. However, the resident's current Advanced Directive Care Plan inaccurately documented the resident as Full Code, indicating full treatment, which was inconsistent with the resident's expressed wishes and documented orders. The discrepancy arose when the Social Service Director, identified as V10, acknowledged that the resident had changed their advanced directives from Full Code to DNR, but the Advanced Directive Care Plan was not updated to reflect this change. The facility's policy requires that any changes in advanced directives be communicated to the attending physician and documented in the resident's medical record and plan of care. This failure to update the care plan resulted in a misalignment between the resident's documented treatment preferences and the care plan, which could potentially lead to inappropriate medical interventions contrary to the resident's wishes.
Failure to Implement Restorative ROM Programs for Residents
Penalty
Summary
The facility failed to develop and implement restorative range of motion (ROM) programs for two residents, R4 and R6, who were identified with functional limitations in range of motion. Both residents were cognitively intact and expressed a desire to receive ROM exercises, yet they were not receiving any therapy, splint/brace assistance, or restorative programs. R4 had hemiplegia affecting the left nondominant side and pain, while R6 had rheumatoid arthritis and limited mobility. Observations revealed that both residents had their hands in closed fists without any assistive devices, indicating a lack of intervention for their ROM limitations. The facility's care plans for R4 and R6 did not address their limitations in range of motion, despite their diagnoses and the residents' own reports of not receiving exercises. The Director of Nursing acknowledged the absence of a restorative nurse or CNA for several months, which contributed to the lack of restorative care for these residents. The facility's policy on restorative nursing services and ROM contracture care outlined the need for individualized programs based on comprehensive assessments, but these were not implemented for R4 and R6. The facility's policies emphasized the importance of restorative nursing care to promote safety and independence, including the development of individualized ROM programs. However, the lack of staff and failure to follow these policies resulted in the deficiency. The facility did not have a system in place to ensure that residents at risk for contractures received the necessary interventions, as evidenced by the lack of ROM exercises and assistive devices for R4 and R6.
Failure to Document Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to ensure that physician-ordered daily weights were obtained for a resident with congestive heart failure. The resident, who has a history of edema, heart failure, and dehydration, was supposed to be weighed daily as part of their care plan. However, the Treatment Administration Records (TAR) for September, October, and November 2024 show multiple instances where the daily weights were not documented, with a total of 17 missed weights in September, 9 in October, and 10 in November. This lack of documentation indicates that the weights were not taken as ordered. Interviews with facility staff revealed that the Certified Nursing Assistants (CNAs) are responsible for taking resident weights, but there is a reliance on agency staff who may not be familiar with the routine, leading to missed weights. The Director of Nursing confirmed the absence of daily weight documentation and acknowledged that there was no record of the resident refusing to be weighed or any notification to the physician about the missed weights. The facility's policy requires that residents with congestive heart failure be weighed as ordered and that significant weight changes be reported to the physician, which was not adhered to in this case.
Failure to Justify and Review Antipsychotic Medication Use
Penalty
Summary
The facility failed to document a diagnosis and identify target behaviors to justify the use of Risperidone, an antipsychotic medication, for a resident diagnosed with Dementia. The resident, referred to as R31, was observed to be calm and cooperative during various times of the day, with no exhibited behaviors that would warrant the use of such medication. Despite being on behavior tracking for verbal aggression and other behaviors, the behavior summary reports for November 2024 indicated that R31 exhibited zero behaviors for the month. The Director of Nursing (V2) acknowledged that since the resident's admission in February 2024, there had been no attempt at a gradual dose reduction of Risperidone, as the psychiatrist did not allow it. Additionally, the facility did not conduct psychotropic medication assessments, which V2 was unaware were necessary. The Social Service Director (V10) confirmed that the resident's behaviors, such as aggression towards staff during care and exit-seeking, were typical of dementia and not indicative of psychosis. The facility's policy on psychotropic medications emphasizes the need for proper ordering, monitoring, and attempts at gradual dose reduction unless clinically contraindicated. However, the facility did not adhere to these guidelines, as there was no documented rationale or diagnosis for the continued use of Risperidone, nor were there attempts at dose reduction. The policy also requires regular review of the medication's necessity and effectiveness, which was not conducted in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Golden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timber Point Healthcare Center | 5.1 mi | ★★★★★ | 2 | 0 |
| Mount Sterling Health And Rehab Center | 15.8 mi | ★★★★★ | 4 | 1 |
| Blessing Hospital Snu | 22.2 mi | ★★★★★ | 0 | 0 |
| Quincy Healthcare & Sr Living | 22.5 mi | ★★★★★ | 2 | 0 |
| Good Samaritan Home | 23 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Golden Good Shepherd Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.