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 Good Shepherd Community Care And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure proper food storage, cleanliness in the kitchen, and dishwasher operation, leading to potential contamination risks for all residents. Observations revealed improperly sealed, labeled, and dated food items, visible dirt and lint in the kitchen, and dishwasher temperatures and sanitizer levels below recommended standards.
The facility failed to update comprehensive care plans for several residents, including those who sustained falls with injuries, required a wheelchair, or needed additional nutritional assistance. Care plans were not revised to reflect significant changes in residents' conditions, leading to gaps in care documentation.
The facility failed to ensure safety and proper documentation, resulting in a resident's fall with injury due to improper equipment use, another resident's bruising from incorrect Hoyer lift transfer, and inadequate supervision of a resident's smoking habits.
The facility failed to ensure that NAs completed their training, competencies, and testing within the required four-month period. Seven NAs continued to work providing direct care to residents without completing a state-approved CNA training program, competency evaluation, and certification test in a timely manner. Interviews revealed that the facility did not have a system in place to ensure timely completion of the CNA training and testing, and the DON and Administrator acknowledged the issue.
The facility failed to consistently reconcile and dispose of controlled medications as required by their policies. Staff did not document medication counts for extended periods, and expired medications were not destroyed in a timely manner. Interviews revealed that staff were not adhering to the required practices for handling controlled substances.
The facility failed to develop comprehensive care plans for residents, neglecting to include critical information about anticoagulant medication and oxygen usage. Staff were unaware of which residents were on blood thinners, and the care plan for a resident on continuous oxygen therapy lacked specific details. The MDS Coordinator and Administrator acknowledged these oversights.
The facility failed to ensure consistent documentation of code status for two residents, leading to discrepancies in their medical records and care plans. One resident's DNR form lacked a physician's signature, and another resident's code status was inconsistently documented as both full code and DNR.
The facility failed to ensure controlled medications were stored securely when an unlocked emergency kit containing Ativan was found in the medication room refrigerator. Staff confirmed that controlled substances should be double locked at all times.
A resident with severe cognitive impairment fell and sustained a foot fracture, but the facility failed to document an assessment and notify the physician in a timely manner. Despite the resident's complaints of pain and a visible bump on the foot, the RN forgot to document the necessary information, leading to a deficiency.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a manner to protect it from possible contamination. Observations revealed that food items in the refrigerator and freezer were not properly sealed, labeled, or dated. Expired and freezer-burnt food items were found, and staff interviews indicated a lack of knowledge and procedures for handling such items. The facility did not have a system in place for checking expired foods, and there was no schedule for performing spot checks for expired foods. This deficiency had the potential to affect all residents who consumed food from the facility kitchen, which had a census of 62 residents. The facility also failed to maintain cleanliness in the kitchen area. Observations showed visible dirt and lint on ceiling vents, window screens, and fans, which could potentially contaminate food and clean dishes. Staff interviews revealed inconsistencies in the cleaning schedule and responsibilities, with some staff unsure of their specific cleaning duties. Maintenance staff were responsible for cleaning vents and windows, but there was no clear schedule or checklist for these tasks, leading to visible dirt and grime in critical areas of the kitchen. Additionally, the facility did not ensure that the dishwasher operated at the recommended temperatures and chemical levels for proper sanitation. Observations and record reviews showed that the dishwasher frequently operated below the required 120 degrees Fahrenheit, and sanitizer test strips did not meet the minimum required levels. Staff interviews indicated a lack of understanding of the correct temperature and sanitizer levels, and there were inconsistencies in documenting and addressing these issues. This failure to maintain proper dishwasher operation and sanitation had the potential to affect the cleanliness and safety of dishes used by all residents.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure the revision of comprehensive care plans to include measurable objectives and timeframes to meet the medical and nursing needs for several residents. Specifically, two residents who sustained falls with injuries, one resident who declined requiring the use of a wheelchair, and one resident who required significant additional nutritional assistance were affected. The facility's policy mandates that care plans be updated when there is a significant change in a resident's condition, but this was not adhered to in these cases. Resident #11, who had severe cognitive impairment and was dependent on staff for mobility and personal care, experienced a fall that resulted in a fracture. Despite this incident, the resident's care plan was not updated to reflect the new fall intervention or the fracture. Similarly, Resident #313, who had severe cognitive impairment and a history of falls, experienced multiple falls, but staff did not update the care plan with new interventions after each fall. Resident #10, who had severe cognitive impairment and required substantial assistance for mobility, was not updated in the care plan to reflect the need for a wheelchair. Additionally, Resident #14, who had severe cognitive impairment and required assistance with feeding and had difficulty swallowing, did not have the care plan updated to include new nutritional orders and interventions. Interviews with staff revealed that care plans were not consistently updated in a timely manner, leading to gaps in resident care documentation and planning.
Failure to Ensure Safety and Proper Documentation
Penalty
Summary
The facility failed to ensure an environment free of accident hazards and provide adequate supervision to prevent accidents. Staff improperly used equipment, resulting in a fall with injury for one resident. The care plan was not updated with new interventions after the fall, and a timely and complete assessment of the resident was not documented. Additionally, staff failed to transfer another resident properly with a Hoyer lift, resulting in bruising to the resident's face, and did not document a full and timely assessment of the bruise received. The facility also failed to ensure an effective system was in place to monitor all residents' ability to smoke and manage smoking supplies. Staff were unclear if a resident could smoke independently and safely, and whether the resident could keep smoking supplies on their person. The resident was observed smoking alone outside without supervision, despite the facility's policy requiring supervision for residents who fall asleep frequently. Interviews with staff revealed inconsistencies in the understanding and implementation of safety protocols, such as the proper use of reclining wheelchairs and Hoyer lifts. The facility's policies on fall risk management, mechanical lifting, and smoking safety were not adequately followed, leading to multiple incidents of resident harm and insufficient documentation of these events.
Failure to Ensure Timely Completion of CNA Training and Certification
Penalty
Summary
The facility failed to ensure that nurse aides (NAs) completed their training, competencies, and testing within the required four-month period. Seven NAs (NA D, NA E, NA F, NA G, NA H, NA I, and NA J) continued to work providing direct care to residents without completing a state-approved certified nursing assistant (CNA) training program, competency evaluation, and certification test in a timely manner. The facility's policy, revised in October 2017, mandates that NAs must complete their training and competency evaluation within four months of hire, but this was not adhered to for the mentioned NAs. Interviews with various staff members, including NAs and registered nurses (RNs), revealed that the facility did not have a system in place to ensure timely completion of the CNA training and testing. NA V, who had been working at the facility for approximately two years, had completed the training but had not yet taken the certification test. Similarly, NA G and NA H had completed their training but faced delays in scheduling and taking their tests due to logistical and financial challenges. The facility's reliance on an online testing service further complicated the timely scheduling of tests. The Director of Nursing (DON) and the Administrator acknowledged the issue, noting that NAs should complete 16 hours of basic skills training and 75 hours of additional competency training within four months. They also mentioned that NAs should be reassigned to non-nursing roles if they fail to complete the training within the stipulated time. However, the facility did not have a clear system to track and enforce these requirements, leading to NAs working beyond the four-month period without proper certification.
Failure to Reconcile and Dispose of Controlled Medications
Penalty
Summary
The facility failed to establish a system of records to ensure all controlled drugs were routinely and consistently reconciled and that discontinued or expired controlled medications were disposed of in a timely manner. The facility's policies required that controlled substances be counted upon delivery, stored securely, and reconciled at the end of each shift. However, the staff did not consistently document medication counts for both active and discontinued narcotics, leading to significant gaps in the records. For example, the Narcotic Overflow Log and the Current Narcotic Overflow Medication Count Inventory Sheet showed multiple instances where staff failed to document medication counts for extended periods, sometimes spanning several months. Observations and interviews revealed that the staff were not adhering to the facility's policies regarding the handling and reconciliation of controlled substances. Registered Nurses (RNs) and the Director of Nursing (DON) admitted that counts were only performed when a red tag was broken or when a medication was used, rather than at the beginning and end of each shift as required. Additionally, the DON acknowledged that expired medications had not been destroyed in a timely manner, with some medications remaining in storage for up to five months. Further interviews with various nursing staff confirmed that the practice of counting controlled medications at the beginning and end of each shift was not being followed. Some staff were unaware of the requirement to check red tags routinely, and others admitted to not having destroyed any discontinued medications recently. The DON and the Administrator both recognized the deficiencies and indicated that they were working on establishing a more consistent process for medication destruction and reconciliation, but these corrective actions had not yet been implemented at the time of the survey.
Failure to Include Anticoagulant and Oxygen Usage in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for all residents, specifically neglecting to include measurable objectives and timeframes for a resident's medical and nursing needs. Resident #11, who was on anticoagulant medication Eliquis for atrial fibrillation, did not have this medication included in their care plan. Interviews with CNAs and RNs revealed that staff were unaware of which residents were on blood thinners, which is crucial information for monitoring potential complications such as bruising or bleeding. The MDS and Care Plan Coordinator acknowledged missing some care plans, and the Director of Nursing confirmed that care plans should include information about blood thinners and precautions. The Administrator also stated that nursing should include a resident's use of anticoagulants on the care plan. Additionally, the facility failed to care plan Resident #46's oxygen usage. This resident, who had diagnoses including congestive heart failure and severe persistent asthma, had a physician's order for continuous oxygen therapy. However, the care plan did not address when and how much oxygen was used or what to monitor related to the use of oxygen. Observations confirmed that the resident was using oxygen continuously, but staff interviews indicated that the care plan lacked specific information regarding oxygen use. The MDS Coordinator and the Administrator both acknowledged that oxygen use should be updated in the care plan. Interviews with various staff members, including the MDS Coordinator and the Administrator, revealed that care plan updates should occur when changes happen or as soon as possible. However, it was noted that any nurse could update a resident's care plan with changes, but typically the Care Plan Coordinator was responsible for these updates. The failure to include critical information about anticoagulant medication and oxygen usage in the care plans led to deficiencies in meeting the residents' medical and nursing needs as identified in their comprehensive assessments.
Inconsistent Documentation of Code Status
Penalty
Summary
The facility failed to ensure a system that clearly and consistently represented each resident's choice of code status. For Resident #46, the Outside the Hospital Do Not Resuscitate (OHDNR) form was signed by the resident but lacked the necessary physician's signature. Despite the resident's moderate cognitive impairment and clear communication of their DNR wishes, the form remained incomplete, leading to a discrepancy in the resident's medical records and care plan, which both indicated a DNR status without the required physician's endorsement. For Resident #20, there was inconsistency in the documentation of the resident's code status. The face sheet and Annual Social Service Care Plan Note indicated a full code status, while the Physician Order Sheet (POS) and care plan showed a DNR status. The resident confirmed that they had recently changed their code status to full code, but this change was not consistently reflected across all medical records. Interviews with staff, including LPNs, the MDS Nurse, the Social Services Coordinator, the DON, and the Administrator, revealed that the process for updating and verifying code status changes involved multiple steps and personnel. However, the discrepancies in the residents' code statuses were not caught or corrected in a timely manner, indicating a breakdown in the facility's system for managing and documenting advanced directives and code status changes.
Failure to Secure Controlled Medications
Penalty
Summary
The facility failed to ensure all controlled medications were stored per standards of practice when a controlled substance was not stored in a locked box. During an observation of the facility's lower nurse medication room, it was found that the medication room refrigerator emergency kit (E-Kit) storage box was unlocked. This box contained six vials of Ativan Intensol, a controlled substance. Registered Nurse (RN M) immediately locked the cabinet and returned the box to the refrigerator upon noticing the issue. RN M confirmed that controlled substances kept in the facility's locked refrigerator for the emergency kit should be double locked at all times. Interviews with the Director of Nursing (DON) and the Administrator confirmed that staff are expected to secure all medications, including storing controlled medications in a double-locked cabinet or refrigerator. The facility's Storage of Medications Policy and the 19 Code of State Regulation (CSR) 30-1.034 both mandate that controlled substances be stored in a securely locked, substantially constructed cabinet. Despite these policies, the Ativan vials were found unsecured, leading to the deficiency noted in the report.
Failure to Document Fall Assessment and Physician Notification
Penalty
Summary
The facility failed to ensure medical records were maintained and accurate in accordance with standards of practice when staff did not timely document an assessment and notification of the physician for a resident who fell and sustained a foot fracture. The resident, who had severe cognitive impairment and was assessed as a fall risk, fell on 03/20/24. Despite the fall, the nursing progress notes did not document an assessment, assessment findings, or notification to the physician after the incident. The resident was found on the floor near their bed after staff heard a crash. The resident was unsteady and crying but was taken to the dining room for breakfast. Later, the resident complained of pain and a bump was discovered on their foot, leading to a transfer to an acute care hospital where a foot fracture was confirmed. The RN who conducted the initial assessment admitted to forgetting to document the physician order for transfer and the assessment in the chart. Interviews with other staff, including RNs and the Medical Director, confirmed that the expected protocol was to document the fall assessment, notify the physician, and conduct follow-up assessments for three days. The Director of Nursing and the Administrator also confirmed that the nurse should document the fall, assessment, and notifications in the nurse notes. However, these steps were not followed in this case, leading to the deficiency.
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 34 citations issued within 25 miles in the last 12 months — including the 1 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 Lockwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Truman Healthcare & Rehabilitation Center | 19.6 mi | ★★★★★ | 6 | 0 |
| Lawrence County Manor | 21.1 mi | ★★★★★ | 14 | 1 |
| Mt Vernon Nursing | 21.4 mi | ★★★★★ | 0 | 0 |
| Ash Grove Healthcare Facility | 21.8 mi | ★★★★★ | 2 | 0 |
| Lake Stockton Healthcare Facility | 22.2 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Good Shepherd Community Care And Rehabilitation.
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.