Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Shepherd Lutheran Home during CMS and state inspections, most recent first.
Outdated Resident Rights Poster: The facility failed to ensure the current RBOR poster was displayed for residents, visitors, and staff to review. Surveyors observed the poster in a locked glass case near the entrance, and it was dated 1/16. The DOSS confirmed it was outdated and said a new one needed to be ordered; no facility policy was provided.
The facility failed to complete SAM assessments and obtain provider orders before leaving medications at the bedside for two cognitively intact residents. Both residents had SAM inquiry forms indicating they did not want to self-administer medications, yet labeled antifungal medications were observed in their rooms and their orders lacked SAM authorization. An LPN stated bedside medications require a doctor’s order and assessment, and the DON confirmed neither resident had a SAM assessment.
Failure to Promote Resident Self-Determination: A resident with CVA, DM2, and difficulty walking had blue mats left on the floor while out of bed, blocking access to the refrigerator. The resident stated he could not reach his pop and yogurt, while an NA, an LPN, and the ADON all stated the mats should be moved out of the way when the resident was not in bed and that he was able to self-propel to the refrigerator.
Inaccurate MDS Coding for Bedrail Use. The facility failed to accurately code the MDS for two residents reviewed for bedrail use. Both residents were cognitively intact and had diagnoses including cardiac conditions and high blood pressure, and both MDS assessments stated they did not use bedrails. However, surveyors observed quarter bed rails on both sides of each bed, and the medical records did not indicate bedrail use. The DON stated the MDS must be accurate because it drives the resident plan of care and reimbursement.
A facility failed to notify the provider about a resident’s weight changes per physician order. The resident had CAD, HF, HTN, and dementia, and the record showed weight fluctuations of 4 lbs and 5 lbs, but there was no evidence the provider was updated. The DON confirmed the provider was never notified and stated the provider should have been informed per the order.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
Failure to assess and obtain consent before bed rail use for two residents. Two cognitively intact residents with diagnoses including AFib, HTN, arthritis, CAD, and HF were observed with bed rails on their beds even though their MDSs indicated no bedrail use. Both records lacked a bedrail assessment, consent, and education, and the DON confirmed no assessment had been completed before the rails were installed.
A resident with restlessness, agitation, pain, palliative care, and a frontotemporal neurocognitive disorder had mismatched Ativan directions across the physician order, narcotic book, EMAR, and bubble pack card. The LPN, pharmacist, and DON all confirmed the entries should have matched, and the pharmacy card lacked notation for the different tablet strength listed in the EMAR.
Medication labeling was deficient in the 500 wing med cart. An LPN observed a Lantus insulin pen with no expiration date and two bottles of Systane eye drops with missing opened-on and/or expiration dates; the LPN stated the cart lacked the stickers needed for proper labeling. The DON stated staff were expected to label items such as eye drops, insulin, nasal sprays, and inhalers with opened-on and expires-on dates when medications were checked in from pharmacy.
The facility did not include required details such as total number and actual hours worked by licensed and unlicensed nursing staff, as well as resident census, on daily posted nurse staffing information. The DON was unaware of these omissions, and there was no policy in place for nurse staffing postings.
The QAPI committee did not maintain effective oversight of a repeat deficiency involving unsafe medication storage, as two medication carts were left unlocked and unattended, and meeting minutes lacked ongoing monitoring data related to this issue.
Surveyors found that food and beverages in facility refrigerators and freezers were not consistently labeled or dated, with some items emitting foul odors, and that ice machines had significant buildup and residue. Staff confirmed these findings and acknowledged that facility policies for food handling and ice machine maintenance were not followed.
A resident with COPD and other chronic conditions, who required extensive assistance and had not been assessed as safe to self-administer medications, was left unsupervised during nebulizer treatments. Staff placed the nebulizer mask and left the room, contrary to physician orders and facility policy, which required staff presence during medication administration unless a self-administration assessment and order were in place.
A resident with COPD and other chronic conditions was administered Budesonide via nebulizer by a medication aide who failed to instruct the resident to rinse her mouth afterward, as required by physician orders and standard practice. Interviews with nursing and pharmacy staff confirmed the omission and the importance of this step to prevent oral infections. The facility's policy required adherence to physician orders, but this was not followed during the observed medication administration.
A resident with paraplegia and a stage 3 pressure ulcer did not receive timely repositioning as required by her care plan, remaining on her back for nearly three hours without assistance. Staff interviews and documentation confirmed the lapse in care, and the facility could not provide a repositioning policy when requested.
Medication carts were observed left unlocked and unattended in two areas, including a memory care unit and another wing. Staff, including an RN and an LPN, walked past the unlocked carts multiple times, leaving them out of direct eyesight for several minutes before securing them. The DON confirmed the expectation that carts should be locked when not in use, especially in areas with residents who have memory impairments. No policy on medication cart security was provided when requested.
Three cognitively intact residents reported that their meals were often served lukewarm or cold, with food temperatures measured below the facility's required 140°F standard. Observations confirmed that items such as meat and vegetables were not at the appropriate temperature when served, and staff were not consistently aware of the required holding temperatures.
Staff did not use required PPE, such as gowns and gloves, while providing high-contact care to a resident on enhanced barrier precautions for a pressure ulcer. Despite being trained and aware of the need for PPE, an LPN and a physical therapy assistant provided care without proper protective equipment, as confirmed by multiple staff interviews and facility policy.
The facility failed to ensure post-dialysis assessment and monitoring for two residents with ESRD. Both residents' care plans lacked specific instructions for post-dialysis care, and staff interviews revealed a lack of training and knowledge regarding dialysis care. The facility's policy did not include guidelines for monitoring residents or training staff, leading to inadequate post-dialysis assessment and monitoring.
The facility failed to maintain records of thorough investigations for four residents related to reported incidents, including missing property, falls, and injuries. Although investigation summaries were provided, evidence of staff interviews was not retained, contrary to the facility's Abuse Prevention Plan.
The facility failed to notify the Ombudsman for LTC of resident transfers to the hospital for two residents. Both residents' Ombudsman Notification of Discharge forms lacked the date and staff signature, indicating they were likely not faxed to the ombudsman as required.
The facility failed to develop comprehensive care plans for two residents requiring dialysis, omitting critical details such as the location of the dialysis graft, dialysis center contact information, and scheduled monitoring post-dialysis. Staff interviews revealed gaps in the care planning process and access to necessary information.
A resident requiring assistance for bathing did not receive a bath for a month, with only one documented refusal and no alternative attempts or documentation of offers. Interviews with staff and the DON confirmed the lack of adherence to the facility's policy on bathing and documentation.
The facility failed to maintain safe storage of medications when medication carts on the 100s and 300s wings were left unlocked and unattended on multiple occasions. Staff confirmed that medication carts should be locked when unattended or out of direct eyesight. The facility policy for medication storage was requested but not provided.
Outdated Resident Rights Poster
Penalty
Summary
The facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights poster was displayed for residents, visitors, and staff to review. On 7/8/26 at 8:47 a.m., surveyors observed the RBOR poster in a locked glass case in a small common area near the entrance, and it was dated 1/16. On 7/8/26 at 12:02 p.m., the Director of Social Services confirmed the poster was outdated and that a new one needed to be ordered. A facility policy was requested but not provided.
Failure to Complete SAM Assessments and Obtain Orders Before Leaving Medications at Bedside
Penalty
Summary
The facility failed to ensure a self-administration of medication (SAM) assessment was completed and a provider order was obtained before medications were left at the bedside for 2 residents reviewed for medication administration. One resident was cognitively intact with diagnoses including atrial fibrillation, high blood pressure, and renal insufficiency. That resident’s SAM inquiry form, signed by the resident, indicated the resident did not want to self-administer medications independently or after set-up by facility staff, yet a bottle of Nystatin powder with the resident’s pharmacy label was observed on the dresser and the resident’s orders lacked a SAM order. A second resident was also cognitively intact with diagnoses including heart failure, high blood pressure, ESRD, and diabetes. The resident’s SAM inquiry form, signed by the resident, likewise indicated the resident did not want to self-administer medications independently or after set-up by facility staff, but a bottle of antifungal powder with the resident’s pharmacy label was observed on the bedside table and the resident’s orders lacked a SAM order. An LPN stated medications could be left at the bedside only if there was a doctor’s order and the resident had been assessed as safe to self-administer. The DON confirmed both residents did not have a SAM assessment and stated her expectation that residents be assessed and have a physician’s order before SAM was put in place or medications were left at bedside.
Failure to Promote Resident Self-Determination
Penalty
Summary
The facility failed to promote independence for one resident with cerebral infarction affecting the left side, type 2 diabetes, and difficulty walking. The resident’s care plan identified a fall risk and directed that blue mats be placed on each side of the bed when in bed to provide a safe environment with even floors free from clutter. During observation, the resident was sitting in a wheelchair while blue mattress mats were left on the floor on the opposite side of the bed and were blocking access to the refrigerator. The resident stated he was not able to access his pop or yogurt in the refrigerator. A nursing assistant stated the resident needed help with ADLs and keeping the room organized, and that staff were expected to move the mats when the resident was out of bed. An LPN stated the resident was able to self-propel enough to retrieve items from the refrigerator and that the mats should not be left on the floor when the resident was out of bed. The ADON stated mats were expected to be removed from the floor and placed out of the way when residents were not in bed, and that it was an issue if a resident could not access the refrigerator when capable of doing so.
Inaccurate MDS Coding for Bedrail Use
Penalty
Summary
Ensure each resident receives an accurate assessment. The facility failed to accurately code the Minimum Data Set (MDS) for 2 of 6 residents reviewed for bedrails. One resident’s comprehensive MDS indicated the resident was cognitively intact with diagnoses including atrial fibrillation, high blood pressure, and arthritis, and Section P stated the resident did not use bedrails; however, during observation and interview, quarter bed rails were present on both sides of the bed, and the resident stated they had been there since admission. Another resident’s quarterly MDS indicated the resident was cognitively intact with diagnoses including coronary artery disease, heart failure, and high blood pressure, and Section P also stated the resident did not use bedrails; however, during observation and interview, quarter bed rails were noted on both sides of the bed, and the resident stated they were not used for positioning. In both cases, the medical record did not indicate the use of bedrails. The DON stated the MDS should be accurately completed with all necessary information because it drives the resident plan of care and reimbursement.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to update the provider about resident R8’s weight changes per physician order. R8’s record showed diagnoses including coronary artery disease, heart failure, hypertension, and dementia, and the annual MDS indicated R8 was mildly cognitively impaired. A physician order dated 7-9-26 directed daily weights and to report a change of 3 lbs overnight. The weight record showed a 4 lb decrease from 153.5 lbs to 149.5 lbs and a 5 lb increase from 148.5 lbs to 153.5 lbs, but the medical record lacked evidence that the provider was ever notified of these changes. The DON confirmed by email that the provider was never updated, and later stated the provider should have been notified per the order.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Failure to Assess and Obtain Consent Before Bed Rail Use
Penalty
Summary
The facility failed to comprehensively assess and attempt alternatives before using bed rails for 2 of 6 residents reviewed for bed rail use. R55’s MDS indicated she was cognitively intact and had diagnoses including atrial fibrillation, high blood pressure, and arthritis. Although Section P of the MDS indicated R55 did not use bedrails, during observation on 7/6/26 her bed had half-length bed rails attached to both sides. R55 stated the rails had been there since admission and that she did not routinely use them. Her medical record lacked an assessment, consent, and education for bedrail use. R16’s quarterly MDS indicated he was cognitively intact and had diagnoses including coronary artery disease, heart failure, and high blood pressure. Section P of the MDS indicated R16 did not use bedrails, but during observation on 7/6/26 his bed had quarter bed rails attached to both sides. R16 stated he did not use them and could not recall how long they had been on his bed. His medical record also lacked an assessment, consent, and education for bedrail use. The DON stated a resident using bedrails required an assessment for appropriateness, a physician’s order, consent, and education, and confirmed R55 and R16 had not had a bedrail assessment prior to installation.
Medication Transcription Mismatch for Narcotic Order
Penalty
Summary
The facility failed to transcribe medication orders according to standards of practice for medication management for one resident with restlessness and agitation, pain, palliative care, and a frontotemporal neurocognitive disorder. The resident’s physician order for Ativan 0.5 mg solutabs directed that 0.25 mg be given by mouth every 4 hours as needed for restlessness, but the corresponding narcotic book page listed Ativan 5 mg every 4 hours as needed, while the EMAR listed 0.5 mg solutabs with directions to give 0.25 mg by mouth every 4 hours as needed. The bubble pack card for Ativan listed lorazepam 0.25 mg solutab with directions to dissolve 1 tablet by mouth three times a day and dissolve 1 tablet by mouth every 4 hours as needed, and the pharmacy card did not include a sticker or other notation to indicate the different tablet strength listed in the EMAR and not on the card. During observation of the medication cart, the narcotic drawer contained the resident’s Ativan 0.25 mg by mouth card, while the narcotic book page listed Ativan 5 mg every 4 hours as needed and the EMAR listed 0.5 mg solutabs with 0.25 mg by mouth every 4 hours as needed. The LPN confirmed the transcribed locations for the same order did not match and should have. The LPN described the facility process for receiving and transcribing new narcotics, including verification by two nurses and use of the index and narcotic book during counts. The pharmacist confirmed all three areas for the order, narcotic book, and card should match and stated that if there was a change in dose or tablet strength, the card should have had a sticker or other notation, but it did not. The DON stated staff were expected to enter orders received from the pharmacy, have two nurses count and verify the medications, write the correct directions for use in the narcotic book, and compare all areas during narcotic count and medication administration. A policy for medication transcription was requested but not provided.
Medication Labeling Deficiency in 500 Wing Cart
Penalty
Summary
Medications and biologicals in the facility were not labeled in accordance with accepted professional principles in the 500 wing medication cart. During observation with an LPN, one Lantus insulin pen was found with no expiration date noted. A box containing two bottles of Systane eye drops was also observed; one bottle had an open date but no expiration date, and the second bottle had neither an opened-on date nor an expiration date. The LPN stated that when medications were received, staff were supposed to place an opened-on/expired sticker on the medication and write the date it was first used and the expiration date on the sticker, but no stickers could be found in the cart during the demonstration. The LPN stated that without an opened-on or expiration date, staff would not know how long a medication had been opened or whether it was safe to use. The LPN also stated that eye drops expire 28 days after opening, and the eye drops dated [DATE] were past expiration. During interview, the DON stated she expected staff to place opened-on and expires-on stickers on medications such as eye drops, insulin, nasal sprays, and inhalers when medications were checked in from pharmacy, and that this information was important to ensure the medication was safe to use and still within its therapeutic level. A policy related to medication labeling and storage was requested but not provided.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that all required data were included on the daily posted nurse staffing information. On multiple consecutive days, the posted nurse staffing information was observed to be missing the total number and actual hours worked by categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. Additionally, the postings did not include the resident census as required. On one occasion, the posted information was also outdated, displaying the previous day's date instead of the current date. Interviews with the Director of Nursing (DON) revealed that she was unaware that the posted nurse staffing information lacked the required details. The DON confirmed that the postings were expected to be updated and accurate so that residents and visitors could know who was providing care. It was also verified that the facility did not have a policy regarding nurse staffing information postings.
Repeat Deficiency in Medication Storage Oversight by QAPI Committee
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement Program (QAPI) committee effectively maintained ongoing compliance regarding repeat citations for drug storage. Specifically, the facility was previously cited for unsafe medication storage when two of seven medication carts were observed left unlocked and unattended. Despite this, a review of QAPI meeting minutes showed a lack of ongoing data and monitoring related to this repeat citation. The facility's policy required monitoring the effectiveness of performance improvement activities, but documentation did not reflect sustained oversight of the previously identified deficiency.
Improper Food Storage and Unsanitary Ice Machines
Penalty
Summary
Surveyors identified multiple instances where food and beverages stored in facility refrigerators and freezers were not labeled or dated as required. Specific items such as yogurt, tartar sauce, mayonnaise, sausage, pepperoni, pork Salisbury steak, whip topping, and various soups and muffins were found without open dates, expiration dates, or any notation of when they were placed in storage. Some items, such as mayonnaise, emitted a foul odor when opened. These issues were observed in both the main kitchen storage areas and resident unit refrigerators. Additionally, ice machines in the facility were found to be inadequately maintained, with significant white flaky buildup and orange residue present on the covers and drip trays. The dietary supervisor, dietary manager, and maintenance director all confirmed these findings during interviews, acknowledging that the facility's policies require food to be dated and discarded appropriately and that ice machines should be kept free of buildup. The facility's own policies specify regular cleaning and scale removal for ice machines and proper food handling procedures, which were not followed.
Failure to Supervise Nebulizer Medication Administration
Penalty
Summary
A resident with diagnoses including arthritis, hypertension, and COPD, who required extensive assistance with activities of daily living, was observed self-administering nebulizer treatments without having been assessed as safe to do so. The resident's care plan indicated dependence on staff for medication administration, and a self-administration of medication (SAM) assessment documented that the resident did not wish to self-administer medications. Physician orders directed staff to administer nebulizer medications, and there was no order permitting self-administration. During observation, a trained medication aide prepared and placed the nebulizer mask on the resident, then left the room and was not within visual sight of the resident during the treatment. The aide returned after the treatment period, found the mask removed by the resident, and repeated the process for a second medication. Interviews with staff confirmed that the resident had not been assessed as safe to self-administer medications and that facility policy required staff to remain present unless a SAM assessment and physician order permitted self-administration. The facility failed to ensure safe administration of nebulizer medications by not supervising the resident as required.
Failure to Ensure Proper Post-Inhalation Care for Steroid Medication
Penalty
Summary
A deficiency occurred when staff failed to follow professional standards of practice related to the administration of an inhalation medication for a resident with chronic obstructive pulmonary disease (COPD), arthritis, and hypertension. The resident required extensive assistance with activities of daily living and had a physician's order for Budesonide inhalation suspension via nebulizer, with explicit instructions to rinse and spit after use to prevent oral infections. During a medication administration observation, a trained medication aide prepared and administered the Budesonide nebulizer but did not instruct the resident to rinse her mouth afterward, as required by the physician's order and medication guidelines. The aide confirmed during an interview that she had not seen the order instructions and that it was not her usual practice to instruct the resident to rinse her mouth after using the Budesonide nebulizer. Further interviews with the registered nurse, pharmacy consultant, and director of nursing confirmed the importance of rinsing the mouth after steroid inhalation to prevent infections such as thrush, and all verified that the resident's orders included this instruction. The facility's medication administration policy also required medications to be administered according to physician orders. The failure to instruct and ensure the resident rinsed her mouth after Budesonide administration constituted a failure to meet professional standards and follow physician orders.
Failure to Provide Timely Repositioning for Resident with Pressure Ulcer
Penalty
Summary
A deficiency occurred when a resident with paraplegia, arthritis, and anxiety disorder, who was identified as being at risk for skin breakdown and having a stage 3 pressure ulcer, did not receive timely assistance with repositioning as required by her care plan. The care plan specified that the resident should be repositioned every two hours while in bed to prevent further skin breakdown. Observations showed that the resident remained lying on her back for nearly three hours without being repositioned, despite staff being aware of her need for frequent turning due to her pressure ulcer. Documentation and staff interviews confirmed that the resident had not been repositioned according to the prescribed schedule. The resident required extensive assistance with activities of daily living, including bed mobility and transfers, and had a chronic wound that required daily dressing changes. Staff interviews and documentation indicated that the resident's care plan and physician orders for wound care and repositioning were not followed. The facility was unable to provide a repositioning policy when requested. The deficiency was identified through direct observation, interviews with staff, and review of the resident's medical records and care plan.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that medication carts were left unlocked and unattended in two separate areas of the facility. On the locked memory care unit, a medication cart was found in a common area and remained unlocked while staff walked past it multiple times. Similarly, on the 100 wing, another medication cart was observed being left unlocked for an extended period while staff, including a registered nurse and a licensed practical nurse, walked past it and left it out of direct eyesight. The cart was only locked after several minutes had passed. During interviews, the registered nurse confirmed that the medication cart was left unlocked for an unknown amount of time and was not within her direct line of sight. The director of nursing stated that the expectation is for medication carts to be locked any time the nurse is away and out of eyesight, emphasizing the importance of this practice, especially in the dementia unit where residents have memory impairments. The facility was unable to provide a policy regarding medication cart security when requested.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature for three residents on the North shore unit, all of whom had intact cognition and were able to feed themselves after staff set up their trays. Multiple residents reported that their food was not always hot, with specific complaints about meat and potatoes being served lukewarm or cold. During meal service, food was observed being plated in the main kitchen, placed on a plate warmer, and then transported to the unit. Upon arrival and distribution, food temperatures were measured and found to be below the facility's required holding temperature of 140°F, with items such as hamburger, chicken, potatoes, and cauliflower ranging from 118°F to 131°F. Residents confirmed that their meals were often only lukewarm or cold, and a dietary aide acknowledged the food was not at the expected temperature. The dietary manager stated that the expectation was for hot food to be held at 140°F or higher, as outlined in the facility's policy. The deficient practice was observed to have the potential to affect all 21 residents on the unit.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use proper personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP) due to a pressure ulcer. The resident, who had moderate cognitive impairment and diagnoses including COVID-19, depression, and metabolic encephalopathy, was care planned for gown and glove use during high-contact care. Observations showed that an LPN cut the resident's toenails without wearing a gown and leaned on the bed, despite being aware of the EBP requirements. Additionally, a physical therapy assistant assisted the resident with walking, transferring, and adjusting bed covers without wearing PPE, even though she acknowledged having received EBP training and knowing the resident was on EBP. Interviews with staff, including the clinical manager, infection prevention nurse, and director of nursing, confirmed that PPE should have been worn during these high-contact care activities. The facility's infection control manual specified gown and glove use for such activities, and all staff, including therapy, had been trained on EBP. Despite this, staff did not adhere to the required precautions during the observed care events.
Failure to Ensure Post-Dialysis Assessment and Monitoring
Penalty
Summary
The facility failed to ensure post-dialysis assessment and monitoring for two residents who required dialysis services. Resident R48, diagnosed with end-stage renal disease (ESRD) and other related conditions, had no orders for daily monitoring of the dialysis graft, removal of the dressing after dialysis, or post-dialysis assessment requirements. The care plan for R48 also lacked specific instructions for monitoring post-dialysis, including the location of the dialysis center and which arm had the graft. Similarly, Resident R108, also diagnosed with ESRD, had no orders for pre or post-dialysis monitoring, and the care plan did not include scheduled monitoring post-dialysis or details about the dialysis center. Both residents' care plans failed to provide comprehensive instructions for post-dialysis care and monitoring, leading to a lack of proper assessment and documentation by the staff. Interviews with staff revealed a lack of specific training and knowledge regarding the care of residents receiving dialysis. Unlicensed staff (NA)-C admitted to not receiving any training on dialysis care, while LPN-B and RN-B indicated that there were no specific protocols or orders for monitoring dialysis residents upon their return. The Director of Nursing (DON) confirmed that the care plans should have indicated if residents received dialysis and that staff should have looked at the calendar for dialysis appointments. However, the DON acknowledged that there were no specific orders or standard monitoring practices for post-dialysis care unless ordered by the provider. The facility's policy on dialysis procedures did not include guidelines for monitoring residents, training staff, or care plan requirements. Additionally, the facility contract with the dialysis center was requested but not provided. The lack of comprehensive care plans, specific orders, and staff training resulted in inadequate post-dialysis assessment and monitoring for the residents, as evidenced by the observations and interviews conducted during the survey.
Failure to Maintain Records of Thorough Investigations
Penalty
Summary
The facility failed to maintain records of thorough investigations for four residents related to reported incidents. For Resident 29, the facility reported a missing tablet and possible financial exploitation to the Minnesota Department of Health (MDH). Although the facility conducted interviews and submitted a summary, they did not provide evidence of the interviews conducted. Similarly, for Resident 318, who was found on the floor with a skin tear and later diagnosed with a hip fracture, the facility's investigation summary lacked evidence of staff interviews despite indicating that interviews were conducted. Resident 319 was found to have a dislocated right shoulder after a fall, and the facility reported the incident to MDH. The investigation summary noted previous shoulder dislocations and denied any harm by others, but again, the facility did not provide evidence of the staff interviews conducted. Lastly, Resident 50 was found outside the facility with multiple injuries, including a head laceration and fractures, after a fall. The facility's investigation summary mentioned staff interviews, but no evidence of these interviews was provided. The assistant director of nursing and the director of nursing stated that their practice was to summarize the information gathered during investigations and include it in the five-day report to MDH, without retaining the evidence of the interviews conducted. The facility's Abuse Prevention Plan indicated that incidents should be reported, documented, and investigated internally, but the facility did not adhere to this policy by failing to maintain records of the investigations and interviews conducted.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for two residents. Resident 42, who had intact cognition and diagnoses including heart and renal failure, was hospitalized from February 14, 2024, through February 19, 2024. The Ombudsman Notification of Discharge form for Resident 42, dated February 14, 2024, indicated that the resident would be transferred to the hospital due to an emergent medical need. However, the form lacked the date and staff signature, suggesting it was not faxed to the ombudsman. Similarly, Resident 49, who had severe cognitive impairment and diagnoses including heart failure and quadriplegia, was hospitalized twice. The Ombudsman Notification of Discharge form for Resident 49's hospitalization on December 31, 2023, also lacked the date and staff signature, and a sticky note on the Verification of Receipt of Notice of Bed Hold for the November 2, 2023, hospitalization indicated the ombudsman form could not be located. The nurse case manager (RNCC) confirmed that the facility's procedure required the nurse who received the order to send the resident to the hospital to fax the signed notification to the ombudsman before filing it in the resident's chart. The RNCC stated that staff were expected to make a notation on the form to indicate it was sent to the ombudsman, and if the form lacked such a notation, it was likely not faxed. The facility's Sending a Resident to the ER form indicated that staff were expected to chart discussions with family about ombudsman notification and fax the form to the ombudsman. However, a specific facility policy regarding required ombudsman notification for transfers/discharges was requested but not provided.
Failure to Develop Comprehensive Dialysis Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents requiring dialysis. Resident R48's care plan did not specify which arm had the dialysis graft, the location of the dialysis center, contact information, or scheduled routine monitoring post-dialysis. Similarly, Resident R108's care plan inaccurately included instructions for a graft that the resident did not have and also lacked details on scheduled monitoring post-dialysis, treatment dates, and dialysis center contact information. Both care plans were missing critical information necessary for proper dialysis care management. Interviews with facility staff revealed gaps in the care planning process. The registered nurse case manager admitted that dialysis appointments were not listed on the care plans and was unsure if unlicensed staff had access to the necessary calendar. The director of nursing confirmed that the care plans did not include the location and contact information for the dialysis centers, expecting staff to look up this information if needed. The facility's policy for care plans was requested but not provided, indicating a potential lack of standardized procedures for care planning.
Failure to Provide Bathing Assistance
Penalty
Summary
The facility failed to provide bathing assistance for a resident (R34) who required partial to moderate assistance for showering and bathing. The resident's quarterly minimum data set (MDS) indicated the need for assistance, and the resident's admission record included diagnoses of chronic pain syndrome, major depressive disorder, and generalized anxiety disorder. Over a 30-day period, the bathing task report showed only one instance of the resident refusing a bath, with no other responses documented. The resident confirmed during an interview that it had been a month since she received a bath, often requesting a bath at a later time when she felt unwell, but staff were not available to accommodate her requests. Progress notes also failed to document any offers or refusals of bathing assistance during this period. Interviews with nursing staff revealed that if a resident refused a bath, alternative options or times should have been offered, and any refusals or completed bed baths should have been documented. The Director of Nursing (DON) confirmed that the facility's policy required baths to be offered and completed on scheduled days, with documentation of any refusals and alternative attempts. The DON acknowledged that the documentation did not reflect proper adherence to this policy, indicating that the resident was not offered or provided a bath during the previous 30 days, except for the one documented refusal. This lack of documentation and adherence to policy resulted in the deficiency noted in the report.
Failure to Maintain Safe Storage of Medications
Penalty
Summary
The facility failed to maintain safe storage of medications when medication carts were left unlocked and unattended in two of six facility medication carts. On multiple occasions, medication carts on the 100s and 300s wings were observed to be unlocked and unattended for varying periods. Specifically, on 4/29/24, a medication cart on the 100s wing was left unlocked and unattended from 4:43 p.m. to 4:55 p.m. On 4/30/24, a medication cart on the 300s wing was left unlocked and unattended from 3:35 p.m. to 3:40 p.m. On 5/1/24, a medication cart on the 100s wing was left unlocked and unattended for approximately one minute at 7:22 a.m. Interviews with facility staff, including a registered nurse and the director of nursing, confirmed that medication carts should be locked any time they are unattended or out of direct eyesight. The facility policy for medication storage was requested but not provided.
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 30 citations issued within 25 miles in the last 12 months — including the 2 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 Sauk Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Country Manor Healthcare And Rehab Center | 1.2 mi | ★★★★★ | 4 | 0 |
| Sartell Therapy Suites | 3.5 mi | — | 0 | 0 |
| Sterling Park Health Care Center | 3.9 mi | ★★★★★ | 0 | 0 |
| Edenbrook Of St Cloud | 4.4 mi | ★★★★★ | 0 | 0 |
| St Benedicts Care Center | 4.9 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Good Shepherd Lutheran 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 August 2026) and official state health department websites.