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 Good Shepherd Nursing Home during CMS and state inspections, most recent first.
A resident was found deceased after staff discovered her with her head and arm between the bed assist rail and mattress. The record showed she had bilateral bed assist rails ordered, limited mobility, and a care plan calling for a safe environment and side rails as ordered. Staff statements and police documentation described her being found kneeling or halfway off the bed with her head wedged between the rail and mattress, and the report stated the facility had not assessed the need for the hand rail assist bars.
An inaccurate bed rail assessment was completed for a resident after the facility did not assess the resident in person for side rail need. The ADM said new beds had been obtained and that side rail safety checks were done for the bed quarterly, but not for each resident’s need for side rails. The DON confirmed the assessment was based on the bed and/or IT discussion rather than a resident-specific evaluation.
Residents were not informed how to file grievances anonymously. Multiple cognitively intact residents stated they knew how to submit a grievance by giving a form to the SW, but did not know how to do so anonymously and said they had never been told where or how to file one. The SW acknowledged residents came to her office to file grievances and knew they did not understand the anonymous process, while the administrator stated the facility did not have grievance boxes and residents could give forms to any staff member.
Missing wall heater access panel covers exposed thin sharp metal edges, wires, and hot pipes in three resident rooms occupied by four residents. Surveyors observed the condition during a walkthrough, and an employee and the maintenance staff member later acknowledged the missing covers and the exposed hazards.
Repeated resident complaints showed long waits for call lights and toileting assistance, with some residents reporting delays of 20 to 50 minutes and staff sometimes turning off the call light without returning. Resident council minutes and grievances also described late meals and staffing shortages, especially on weekends, and the DON acknowledged the concerns. Staff said they sometimes had to manage with reduced staffing and one aide covering an entire hallway.
A facility failed to ensure pharmacist MRR recommendations were reviewed, addressed, and signed by the MD. One resident had unsigned recommendations related to weight loss and low BP, while several other residents had MRRs without MD signatures, actions, or rationale documented. The facility policy required the MD to sign agreement or disagreement with the consultant pharmacist's recommendations.
Unsafe food and supply storage was observed in the kitchen and resident pantries. Surveyors found 4 half gallons of expired milk in the walk-in refrigerator, and the Dietary Manager confirmed the milk was expired. Surveyors also found medical ice packs stored in resident freezers in 4 of 5 pantries, and the Dietary Manager confirmed they should not be stored with resident food.
Water Management Plan Missing Required Legionella Controls: The facility failed to maintain a water management plan that followed CDC standards and included measures to control and prevent Legionella and other opportunistic waterborne pathogens. The MD provided legionella test results, temp logs, and flushing/disinfection logs, but did not have a copy of the plan. The Administrator later produced a plan that described the water system and semi-annual Legionella/HPC testing, but it did not include the monthly control measures being performed or the testing locations, and the contract submitted did not include a water management plan or water management services.
Resident Left Undressed in Hallway A resident was observed in a wheelchair outside his room wearing only a brief and clearly visible to staff and other residents in the hallway. Staff passed by without concern until an LPN was alerted, stated she did not know why he had not been dressed yet, and then wheeled him back to his room and directed a NA to help him get dressed.
Unsanitary Bathroom Conditions: A resident bathroom had discolored residue buildup at the base of the pipe behind the raised toilet seat, and another bathroom had two dried brown smears on the wall below the toilet seat. During a later walk-through, an LPN acknowledged the brown smears and the residue buildup was still present.
Failure to notify the Ombudsman of a resident’s discharge. Record review showed a resident was transferred to the hospital and the POA, family members, and responsible party were notified, but the SW could not verify Ombudsman notification and the Administrator confirmed no record of it.
A resident’s PASARR was not updated after a new diagnosis of Paranoid Schizophrenia was added after admission. The admission PAS indicated no Level II review was needed and listed other developmental disabilities, but the record showed no new PAS to address whether specialized services were needed. The DON confirmed the PAS did not reflect the schizophrenia diagnosis and had never been updated.
A resident had an order for Sensipar 30 mg daily for elevated calcium, and FDA/PDR guidance states it should be taken with food or shortly after a meal and swallowed whole. The DON said it was given at mealtime and that med pass times matched meals, but the facility’s med administration schedule showed once-daily meds were given between 8:00 AM and 10:00 AM.
A resident had multiple recorded weight changes that met the facility’s trigger for a re-weigh and MD notification, but no re-weigh or provider notification was documented. The facility policy required weekly weights for significant loss, verification of a 5 lb change, and nurse oversight, yet an LPN was unsure of the policy and the DON stated there was no specific Nursing Supervisor assigned to monitor weights.
The facility failed to ensure pharmacist MRR recommendations were reviewed and signed by the MD for two residents. Record review showed no electronic or hard copy documentation of physician response, and the last two MRRs for both residents were unsigned despite sign-here tags being in place. The pharmacist stated copies were placed in the hard chart for MD review and signature.
Failure to Assess Bed Assist Rail Safety
Penalty
Summary
The facility failed to provide an environment free from accident hazards by not assessing the need for hand rail assist bars. Resident #100 had bilateral bed assist rails ordered for turning and repositioning, and the care plan noted limited mobility of both upper and lower extremities, the need for prompt response to requests for assistance, a safe environment, and side rails as ordered. The record also showed that the resident was found deceased with her head and arm between the hand rail and mattress. According to the incident documentation, staff entered the resident’s room and found her lower body on the floor while her head was between the hand-held assist rail and the mattress. Staff placed her back into bed and determined she had no vital signs. The physician, DON, Administrator, and MPOA were notified. The physician later documented that the resident was found with her head wedged between the rail and mattress, that her arm was also wedged and discolored, and that petechiae were present on her face. Staff statements described that the resident had been put to bed earlier in the evening and was later found kneeling on the floor next to the bed with her head between the siderail and mattress. One nurse aide stated the resident had no pulse when found. Another aide stated the resident was found with her head between the rail and bed and her body angled toward the mattress. Police documentation also stated that the resident was found halfway off the bed with her head wedged between the mattress and handrail. The facility census was 174, and the report stated that all residents except one had bilateral hand rail assist bars.
Incomplete Bed Rail Assessment
Penalty
Summary
The facility failed to complete an accurate bed rail assessment for Resident #100. The report states that the current assessment did not fully assess the resident’s risks and needs for side rails. During an interview, the Facility Administrator reported that new beds had recently been obtained for everyone except bariatric residents and denied that any resident had been assessed for the need for bed rails. She also stated that Side Rail Safety Assessments were completed for the beds quarterly, but not for the need for side rails as they pertain to specific residents. A review of the GSNH-Side Rail Safety Assessment showed that the questions were assessed by looking at the bed and/or through an Interdisciplinary Team discussion rather than by assessing the resident in person, as confirmed by the DON. The assessment included items related to mattress and side rail spacing, latch stability, air mattress or overlay movement, and whether head-of-bed elevation created a gap, along with a list of possible interventions and alternatives such as bed alarms, low bed, side rails, mats, scheduled toileting, and frequent staff monitoring.
Residents Not Informed How to File Anonymous Grievances
Penalty
Summary
The facility failed to ensure residents knew they had the right to file grievances anonymously. During an entrance observation and resident interviews, Resident #470 stated she did not know how to file a grievance anonymously, and Resident #26 also stated she did not know how to file a grievance or complaint anonymously. Review of the most recent MDS Section C showed both residents had capacity and were cognitively intact. During a resident council meeting, multiple residents in attendance, including Residents #23, #48, #19, #78, #86, #123, and #164, stated they knew how to file a grievance by completing a form with the social worker, but they did not know how to file one anonymously and said they had never been told how or where to do so. Review of the facility grievance policy stated residents have the right to file grievances without discrimination or reprisal and that the facility will notify residents individually and through postings of the right to file grievances verbally, in writing, or anonymously. The social worker confirmed residents come to her office to file grievances and acknowledged residents did not know how to file grievances anonymously. The administrator stated she was unaware residents did not know how to file grievances anonymously and said the facility did not have grievance boxes on the wall for resident safety, and residents could give forms to any staff member.
Missing Heater Access Covers Exposed Hazards in Resident Rooms
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to provide adequate supervision and assistance devices to prevent accidents. During an entrance walkthrough, surveyors observed that wall-mounted heater maintenance access panel covers were missing in three resident rooms, exposing thin sharp metal edges, wires, and hot pipes. The affected rooms were occupied by Residents #58, #146, #33, and #74. During a later walk-through, an employee acknowledged that the heater maintenance access panel covers were missing and exposing the sharp edges, wires, and hot pipes, and the maintenance employee confirmed the condition and stated he had a plan for replacement covers.
Delayed Response to Call Lights and Resident Needs
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet resident needs and to ensure a licensed nurse was in charge on each shift, as shown by repeated resident and family complaints about long waits for assistance. Resident interviews described delays of 20 to 50 minutes for help with toileting, including one resident who said she waited 45 minutes to be taken to the restroom and another who reported calling staff four times during a 45-minute wait while using the exercise bike in the day room. A resident also stated that staff sometimes turned off the call light, said they would return, and did not come back, forcing the resident to push the call button again. Resident council meeting minutes and grievance records showed the same concerns had been raised repeatedly over several months, including complaints that call lights were answered slowly, staff turned off call lights and did not return for long periods, and meals were sometimes served late. Residents reported that these delays occurred mostly on weekends and sometimes on day shifts. The DON acknowledged the resident complaints of long waits for call lights to be answered. Nursing staff interviews indicated that when staff called out, those on duty had to manage with fewer staff and sometimes one aide had to care for an entire hallway alone.
Unsigned Pharmacist Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly medication regimen review recommendations made by the consulting pharmacist were reviewed, addressed, responded to, and signed by the physician. For Resident #16, the pharmacist documented recommendations on 03/11/25 related to significant weight loss and possible appetite medication, and on 07/16/25 related to several soft blood pressures and the need for blood pressure medication monitoring/hold parameters. There was no review, acknowledgement, or physician signature for either recommendation, and the recommendations remained unsigned. During interview, the DON was unable to provide documentation showing that the physician had reviewed and responded to the pharmacist's recommendations. For Resident #19, Resident #15, Resident #1, and Resident #23, the medical record review showed monthly drug regimen review responses without physician signature, action, or rationale when no action was taken. Resident #19 had pharmacist recommendations regarding Trulicity titration and blood sugar management, and Resident #15 had recommendations regarding blood sugar management and significant weight gain with possible medication adjustment and lipid panel review. Resident #1 and Resident #23 each had two medication regimen reviews dated 06/30/25 and 07/31/25 that were not signed, with sign-here tags present for the MD. The facility policy stated the physician must sign whether they agree or disagree with consultant pharmacist recommendations, and if the form was not signed or comments were not made during the physician visit, the RN would call the physician or fax the form for comments.
Unsafe Food and Supply Storage
Penalty
Summary
Food was not stored in a safe sanitary manner in the facility’s kitchen and resident pantries. During an initial kitchen tour, surveyors observed 4 half gallons of milk in the walk-in refrigerator that were expired, and the Dietary Manager confirmed the milk was expired during interview. During a tour of the resident pantries, surveyors also found medical ice packs stored in resident freezers in 4 of 5 pantries, and the Dietary Manager confirmed that the medical ice packs should not be stored with resident food.
Water Management Plan Missing Required Legionella Controls
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program because it did not have a water management plan that followed nationally accepted CDC standards and incorporated measures to control and prevent Legionella and other opportunistic waterborne pathogens. During interview, the Maintenance Director provided legionella testing results for four locations, monthly temperature logs, and monthly flushing and disinfection logs for dead ends, unused rooms, equipment, and showers, and stated there had been no outbreaks of Legionella or other waterborne infections. However, when asked for the Water Management Plan, the Maintenance Director stated he did not have a copy. The Administrator later produced a Water Management Plan that described the building water system, water temperatures, backflow prevention, chlorine use for the garden fountain, and semi-annual Legionella/HPC testing by SDI Environmental. The plan did not incorporate measures to control and prevent Legionella and other opportunistic waterborne pathogens that followed nationally accepted standards, did not include the monthly measures the Maintenance Director said were being performed, and did not identify the locations where Legionella testing had occurred. The Administrator confirmed the maintenance department did not have a copy of the Water Management Plan and stated maintenance staff relied on a contracted water management company for monthly actions and protocols. A submitted quotation for legionella testing referenced annual and bi-annual culture-based testing, but the contract did not include a water management plan or an arrangement to provide water management services to the facility.
Resident Left Undressed in Hallway
Penalty
Summary
The facility failed to promote Resident #41’s right to a dignified existence when, on 08/20/25 at approximately 9:31 AM, the resident was observed in a wheelchair outside his room wearing only a brief and was clearly visible to staff and other residents walking down the hallway. Staff members were seen passing by the resident without expressing any concern about his attire. When the concern was brought to the attention of an LPN, she stated, "I don't know why he hasn't been dressed yet!" and then wheeled the resident back to his room and instructed a NA to help him get dressed. The DON was notified of the finding at approximately 10:30 AM.
Unsanitary Bathroom Conditions
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in room [ROOM NUMBER] and room #340. During survey observations and resident interviews on 08/18/25, a discolored residue buildup was found at the base of the pipe behind the raised toilet seat in one bathroom, and two dried brown substance smears were observed on the right-side wall below the toilet seat in another bathroom. On 08/20/25, during a walk-through with Employee #136, the brown smears in room [ROOM NUMBER]'s bathroom were acknowledged, and the discolored residue buildup in room [ROOM NUMBER]'s bathroom was still present.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the Long-Term-Care Ombudsman of Resident #188’s discharge from the facility. Record review showed the resident was transferred to the hospital on [DATE], and the resident’s POA was notified on 05/24/25. During interview, Social Worker #183 presented documentation verifying that the resident’s family members and responsible party were notified, but she could not confirm whether the Ombudsman had been notified and later stated she had no documentation to verify that notification. The Administrator also confirmed that no record of notification to the Ombudsman could be found.
Failure to Update PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to update the PASARR for Resident #19 after the resident was diagnosed with Paranoid Schizophrenia following admission. The resident’s admission PASARR dated 08/31/23 indicated that no Level II review was needed, and Section III #30 of the MI/MR assessment listed other developmental disabilities. A subsequent record showed the diagnosis of Paranoid Schizophrenia was added after admission, but the resident did not receive a new PAS to address whether specialized services were needed. During interview on 08/21/25 at 11:06 AM, the DON confirmed the PAS presented to the surveyor did not indicate Paranoid Schizophrenia and had never been updated.
Failure to Clarify Food Requirement for Sensipar Order
Penalty
Summary
The facility failed to ensure clarification of a resident’s medication order for Sensipar (cinacalcet) 30 mg, ordered once daily for elevated calcium. Record review showed the order dated 05/01/25 for the resident to receive 1 tablet by mouth daily. FDA guidance and the PDR, reviewed with the DON, state that cinacalcet should be taken with food or shortly after a meal and swallowed whole. During interview, the DON stated the medication was given at mealtime and said the facility’s mealtimes coincided with medication administration times. However, the medication administration schedule provided by the facility showed that once-daily medications were scheduled for administration between 8:00 AM and 10:00 AM.
Failure to Re-Weigh and Notify Provider for Significant Weight Changes
Penalty
Summary
The facility failed to follow its weight policy for Resident #51 by not re-weighing the resident or notifying the medical provider when multiple recorded weights showed significant changes. Record review showed five weight entries between 01/01/25 and 08/12/25 that met the facility’s trigger for a re-weigh, including weights of 145.8 lbs, 143 lbs, and 133 lbs with documented percentage changes of 5% or more from prior weights. On each of these occasions, there was no re-weight performed and no notification to the MD documented. The facility policy stated that residents with significant weight loss of 5% in 30 days or 10% in 180 days were to be weighed weekly until stable, and that a 5 lb change from the previous weight required a re-weigh to verify accuracy. During interview, an LPN stated that aides typically obtained weights and nurses were told if there was a big difference, but she was unsure of the actual policy and when a re-weigh was needed. The DON stated there was no specific Nursing Supervisor assigned to check resident weights and that monitoring was handled by each section.
Physician Did Not Review or Sign Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were reviewed, addressed, and responded to by the physician for 2 of 4 sampled residents, Resident 1 and Resident 23. Record review showed that the medication regimen review (MRR) was not signed into either resident’s chart, and there was no electronic or hard copy documentation showing physician review of the pharmacist recommendations. For both residents, the last two MRRs dated 7/31/25 and 6/30/25 were missing the MD signature, although sign-here tags were in place for the physician. During interview, the pharmacist stated that copies of the recommendations were placed in the hard chart for the MD to review and sign.
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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 Wheeling
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continuous Care Center Wheeling Hospital | 0.8 mi | ★★★★★ | 5 | 0 |
| Peterson Rehabilitation And Healthcare | 0.8 mi | ★★★★★ | 7 | 0 |
| East Ohio Regional Hospital Long Term Care | 2.6 mi | — | 0 | 0 |
| Rolling Hills Rehab And Care Ctr | 5.4 mi | ★★★★★ | 18 | 1 |
| Country Club Retirement Ctr Iv | 6.6 mi | ★★★★★ | 19 | 0 |
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