Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Lutheran Home Of The Good Shepherd during CMS and state inspections, most recent first.
A resident with polyneuropathy, reduced mobility, severe obesity, and fall risk was injured during van transport when her left sock became caught in a pinch point on the lift platform. Staff reported that her arms and legs were in proper position, but on the return trip they found bleeding from her left 4th toe; the hospital reported a fracture and laceration requiring sutures. The facility’s van transport policy did not address keeping extremities within the wheelchair frame or supported during loading.
Medication administration errors were observed for two residents. One resident’s Gabapentin was documented as given at the scheduled time even though it was actually administered later, and another resident with DM and insulin dependence had an insulin pen primed incorrectly by an LPN. The facility also lacked a policy on medication administration and documentation.
Failure to follow hand hygiene and glove-use standards was observed during care for two residents. A CNA transferred one resident, completed perineal care, then handled room items before performing hand hygiene; for another resident, two CNAs used soiled gloves to access bag balm, apply it to the resident, and adjust the resident's necklace without changing gloves or cleaning hands. In a separate dressing change, an RN exited the room with a soiled glove and opened the nurse's cart drawer to get more supplies before removing the glove and performing hand hygiene.
A resident with a history of stroke and left-side paralysis, dependent on staff for all transfers, sustained a right ankle fracture after being transferred with a Hoyer lift by a CNA without the required second staff member. The resident reported pain and swelling following the transfer, and staff interviews confirmed that the two-person transfer protocol was not followed on multiple occasions, resulting in injury.
A nurse in an LTC facility failed to follow infection control standards during blood glucose testing by using a glucometer labeled for one resident on another without proper disinfection. The nurse used an alcohol wipe instead of the recommended Sani-Cloth, which was unavailable. This breach in protocol led to an Immediate Jeopardy situation due to the risk of bloodborne pathogen transmission.
A facility failed to update a resident's care plan to reflect their current mobility status, which limited staff's ability to communicate needs and ensure continuity of care. The care plan inaccurately stated that the resident transferred with supervision and used a walker, while observations showed the resident using a wheelchair independently. An administrative staff member confirmed the care plan was not updated.
Two residents in the facility received medications improperly due to staff failing to follow professional standards. A medication aide applied Nystatin powder without a physician's order, and a nurse crushed a Potassium Chloride ER tablet, contrary to the prescribed method. Both actions were confirmed as incorrect by administrative staff, highlighting a breach in the facility's medication administration policy.
The facility failed to secure hazardous areas, allowing a resident access to an unlocked laundry room with chemicals, and did not use a gait belt during a toileting transfer for a resident, contrary to the care plan. Staff confirmed these areas should be locked and gait belts used as per policy.
The facility failed to label medications properly, as observed during a medication pass for two residents. A nurse administered artificial tears without a label, and another nurse used nasal spray with dosage instructions that differed from the MAR and physician's order. These actions did not comply with professional standards, risking medication errors.
Inadequate Supervision During Van Transport
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent an accident during van transport for one sampled resident. Resident #36 had diagnoses including a laceration/nondisplaced fracture of the middle phalanx of the left lesser toe, polyneuropathy, reduced mobility, and severe obesity. The resident’s care plan identified that she was at risk for falls because she was unaware of safety needs and unable to use her legs, and that staff should anticipate her needs. The facility policy for safe lift and/or ramp usage in vans directed staff to open doors, lower the lift, load the resident with brakes on, and transfer the resident into placement, but it did not address keeping the resident’s extremities within the wheelchair frame or supported during loading. During transport, maintenance staff and CNAs transferred the resident by wheelchair onto the loading platform on the back of the facility van and reported that safety checks were completed and the resident’s arms and legs were in proper position. While the platform was being raised, staff noticed the tip of the resident’s left gripper sock was caught between the platform and the van. The sock was removed and the resident and wheelchair were secured in the van. On the return trip, staff noticed the resident’s left foot sitting in a small pool of blood, removed the sock, and found significant bleeding from the left 4th toe. The resident was taken back to the ER, where the hospital reported a broken left 4th toe and a 0.5 cm laceration with five sutures placed. The FRI stated that four staff members went with the transport van because the resident was obese and difficult to transfer, and that the resident’s sock was caught in a pinch point on the platform.
Medication Administration Errors and Late Documentation
Penalty
Summary
The facility failed to ensure staff followed professional standards of practice for 2 of 4 sampled residents during medication administration. Facility policy titled Insulin Pen Use stated to prime the pen with 2 units of insulin while pointing the pen with the needle upwards, and a professional reference stated that medication documentation should occur after administration and include the exact time given. The facility did not provide a policy on medication administration and documentation. Resident #36 had physician’s orders for Gabapentin by mouth three times daily, with MAR times listed as 7:00 a.m., 2:00 p.m., and 7:00 p.m. During observation, a nurse conducted a narcotic count and the resident’s Gabapentin record showed 2 tablets, while the medication cartridge contained 3 tablets. The MAR showed the nurse signed the 2:00 p.m. dose as given, but observation showed the Gabapentin was actually administered at 4:30 p.m. Resident #6 had diagnoses of type 2 diabetes mellitus and insulin dependence, with orders for Novolog 70/30 insulin with meals and sliding scale. During observation, a nurse primed the insulin pen pointed sideways instead of upward, and an administrative nurse confirmed the insulin pen was not correctly primed.
Failure to Follow Hand Hygiene and Glove Use Standards
Penalty
Summary
The facility failed to follow infection control and prevention standards for 2 of 14 sampled residents during observed care. The facility policy titled Personal Protective Equipment, revised July 2022, stated that staff should perform hand hygiene before donning gloves and after removal, and should change gloves and perform hand hygiene between clean and dirty tasks and when moving from one body part to another. During observation of care for one resident, a CNA used a sit-to-stand lift to transfer the resident from a wheelchair to the toilet, applied gloves, performed perineal care, removed the soiled gloves, and transferred the resident back to the wheelchair. Without performing hand hygiene, the CNA opened the room blinds and moved the overbed table within the resident's reach before performing hand hygiene and leaving the room. During observation of care for another resident, two CNAs performed perineal care in bed. One CNA opened a nightstand drawer, removed a container of bag balm, opened and reached into the container with a dirty gloved hand, and applied the bag balm to the resident's inner thighs without changing gloves or performing hand hygiene. After the resident was transferred from bed to wheelchair, the other CNA adjusted the resident's necklace without removing soiled gloves or performing hand hygiene. In a separate observation, a nurse performed a dressing change for the same resident, used gauze to pat open skin on the inner thighs, discarded the gauze, removed the soiled right glove, and exited the room without removing the soiled left glove or performing hand hygiene before opening the nurse's cart drawer and obtaining more dressing supplies.
Failure to Follow Two-Person Hoyer Lift Transfer Policy Resulting in Resident Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's policy and the resident's care plan requiring two staff members to assist with all Hoyer lift transfers. A resident with mild dementia, anxiety, and left-side hemiplegia following a stroke, who was dependent on staff for all transfers, sustained a right ankle fracture of unknown origin. The resident reported pain and swelling in the right ankle after a transfer, and upon assessment, a hairline fracture was identified. The resident stated that a CNA transferred her without using the correct lift and dropped her, although the CNA denied dropping or injuring the resident. Video evidence confirmed that a CNA performed a Hoyer lift transfer alone the evening before the injury, and another CNA also admitted to transferring the resident with the Hoyer lift without a second staff member present. The facility's investigation found that the required two-person assistance for Hoyer lift transfers was not followed by staff on multiple occasions. The failure to adhere to established transfer protocols and the resident's care plan resulted in the resident sustaining a fracture from an unknown source. The incident was determined to be past non-compliance after review of the events and staff interviews.
Infection Control Breach During Blood Glucose Testing
Penalty
Summary
The facility failed to adhere to infection control standards during blood glucose testing for three residents. Observations revealed that a nurse used a glucometer labeled for one resident to check another resident's blood sugar, without proper disinfection. The nurse attempted to use Resident #8's glucometer for Resident #7, who was not routinely checked for blood sugar, indicating a breach in protocol. Additionally, the nurse cleaned the glucometer with an alcohol wipe instead of the manufacturer's recommended Sani-Cloth, which was not available in the cart at the time. The manufacturer's instructions for the Assure Prism blood glucose meter specify that the device should be cleaned and disinfected after each use to prevent the transmission of bloodborne pathogens. The instructions also state that only specific EPA-registered wipes, such as PDI Super Sani-Cloth Germicidal Disposable Wipes, are validated for use. The improper cleaning and sharing of glucometers placed residents at risk of exposure to bloodborne pathogens, leading to the identification of an Immediate Jeopardy situation by the survey team.
Failure to Update Resident's Care Plan
Penalty
Summary
The facility failed to review and revise the care plan for one resident, which limited staff's ability to communicate needs and ensure continuity of care. The care plan for the resident, who was observed using a wheelchair for mobility, was outdated and did not reflect the resident's current status. The care plan inaccurately stated that the resident transferred with supervision and ambulated with a walker, despite observations showing the resident moving independently in a wheelchair. An administrative staff member confirmed the failure to update the care plan to reflect the resident's current mobility status.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of medications for two residents. In the first instance, a medication aide applied Nystatin powder to a resident's perineal area without a physician's order. This action was observed during routine care, and a review of the resident's medical record confirmed the absence of an order for the medication. The facility's policy requires that all medications be administered according to the six rights of administration, which includes obtaining a physician's order. In the second instance, a nurse crushed and administered a Potassium Chloride extended-release tablet in pudding to another resident. The resident's medical record contained a physician's order for the medication to be given as an extended-release oral tablet, which should not be crushed. An administrative staff member confirmed that the nurse administered the medication incorrectly and reiterated that all medications should have a physician's order. These actions demonstrate a failure to follow the facility's medication administration policy and professional standards of practice.
Failure to Secure Hazardous Areas and Use Assistive Devices
Penalty
Summary
The facility failed to ensure an environment free from accident hazards in a special care unit, as observed when a resident accessed an unlocked laundry room containing hazardous chemicals such as bleach and laundry detergent. Despite the expectation that the laundry room door should automatically lock when closed tightly, it remained unlocked, allowing resident access. Additionally, the soiled utility room door was observed unlocked, containing various cleaning agents and disinfectants, posing further risks. Interviews with staff confirmed that these doors should remain locked to prevent resident access to potentially dangerous substances. The facility also failed to provide appropriate assistance and assistive devices during a toileting transfer for a resident. The resident's care plan required the use of a gait belt and a front-wheeled walker for transfers, yet two CNAs assisted the resident by lifting under the arms without using a gait belt. This action was contrary to the facility's policy, which mandates the use of a gait belt for residents needing hands-on assistance for balance or lifting. An administrative staff member confirmed that staff should adhere to the policy and care plans during transfers.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to label medications in accordance with professional standards, as observed during a medication pass for two residents. During an observation, a nurse prepared medications for a resident and administered artificial tears that lacked a label with identifying information, such as the resident's name. This oversight in labeling medications could lead to medication errors, as it does not comply with the professional standards outlined in Kozier & Erb's Fundamentals of Nursing. In another instance, a nurse removed nasal spray from the medication cart for a different resident. The label on the medication indicated a dosage of two sprays to each nostril twice daily, which was inconsistent with the medication administration record (MAR) and the physician's order that specified two sprays each nostril once daily. This discrepancy in labeling and administration instructions further highlights the facility's failure to adhere to proper medication labeling and administration protocols.
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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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Nursing homes near New Rockford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Acres Manor | 19.3 mi | ★★★★★ | 1 | 0 |
| Eventide Heartland | 33 mi | ★★★★★ | 10 | 0 |
| Smp Health - St Aloisius | 37 mi | ★★★★★ | 0 | 0 |
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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.