Good Shepherd Home Raker Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were free from potential chemical restraints for one of five sampled residents who were ordered psychotropic medications. (Resident 26) Findings include:Clinical record review revealed that Resident 26 had diagnoses that included mood disorder and dementia. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively impaired and had been administered an anti-anxiety medication. On June 16, 2025, a physician ordered staff to administer an anti-anxiety medication, (alprazolam), every eight hours as needed for anxiety and agitated behaviors. There was no date in the order that indicated when staff was to stop administering the as needed medication. Review of Resident 26's Medication Administration Record revealed that staff had administered the alprazolam 21 times in July 2025, 17 times in August 2025, and 17 times in September 2025. There was no documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessments were completed to accurately reflect the residents' current status for three of 20 sampled residents. (Residents 1, 2, and 7) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included cerebral atherosclerosis and coronary artery disease. A physician's order dated July 1, 2025, directed staff to administer an anti-platelet medication (clopidogrel bisulfate). Review of the MDS assessment dated [DATE], revealed that the resident was administered an anti-coagulant medication during the review period, not an anti-platelet medication. The MDS inaccurately reflected the use of an anti-coagulant medication. Clinical record review revealed that Resident 2 had diagnoses that included peripheral artery disease and depression. A physician's order dated October 9, 2023, directed staff to administer an anti-platelet medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed each resident's needs as identified in the comprehensive assessment for two of 20 sampled residents. (Residents 16 and 36)Findings include: Clinical record review revealed that Resident 16 was admitted to the facility on [DATE], and had diagnoses that included adjustment disorder. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated March 20, 2025, noted that the resident's psychotropic drug use was to be addressed in the care plan. Review of the medication administration records for March through September 2025, revealed the resident received an antidepressant (sertraline), which was classified as a psychotropic drug, during the review period. There was no documented evidence that interventions to address Resident 16's psychotropic drug use were included in the current care plan. In an interview on September 22, 2025, at 3:20 p.m., Registered Nurse 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and review of facility documentation, it was determined that the facility failed to store and serve food under sanitary conditions in the kitchen. Findings include: Observation of the kitchen on August 20, 2024, at 10:15 a.m. revealed the following: There were two fruit flies in the food preparation area. There was a large fly on the cold preparation station. There was a pan of chicken on the same preparation station. The plastic wrap on the pan did not fully cover the pan and the chicken was open to air. There was an uncovered garbage can by the coffee preparation station. There was cheese in the reach in refrigerator with a use by date of August 18, 2024. There was a cup used to scoop thickener powder that was stored in the container, in direct contact with the thickener. Observation of the tray line service on August 21, 2024, at 11:10 a.m., revealed the following: Dietary Employee 1 (DE 1) was wearing gloves and operating the tray line. On multiple occasions, DE 1 turned away from the tray line and obtained food items from the refrigerator. DE 1 returned to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and resident interview, it was determined that the facility failed to ensure that a call bell was accessible for one of 20 sampled residents. (Resident 53) Findings include: Clinical record review revealed that Resident 53 had diagnoses that included multiple sclerosis (damage to the nerves), quadriplegia (paralysis that affects all limbs of the body), and depression. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had no cognitive impairment and was dependent on staff for activities of daily living. Review of the care plan revealed that staff was to ensure that the resident's call bell was within reach at all times. On August 20, 2024, at 1:07 p.m., Resident 53 was observed in her wheelchair in her room. The resident stated she wanted assistance to go back to bed. The call bell was placed on top of the resident's bed. The resident stated that the call bell was difficult to reach when it was on top of her bed. On August 21, 2024, at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the Resident Assessment Instrument (RAI) User's Manual and clinical record review, it was determined that the facility failed to timely complete and transmit Minimum Data Set (MDS) assessments for three of 20 sampled residents. (Residents 32, 48, 67) Findings include: The Long Term Care Facility RAI User's Manual which provides instructions and guidelines for completing required MDS assessments, (mandated assessments of a residents' abilities and care needs), dated October 2019, indicated that annual, quarterly, and admission assessments were to be completed and transmitted electronically to the Centers for Medicare/Medicaid services (CMS) no later than 14 days after the Assessment Reference Date (ARD) which refers to the last day of the assessment observation period. Clinical record review revealed that Resident 32 had a quarterly MDS assessment, dated July 11, 2024, with an ARD of July 26, 2024, noted as still in progress and had not yet been completed or transmitted as per the time requirements. This quarterly assessment was overdue and had not been completed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for two of 20 sampled residents. (Residents 50, 61) Findings include: Clinical record review revealed that Resident 50 had diagnoses that included myotonic muscular dystrophy (genetic disorder that causes progressive muscle loss), congestive heart failure, and respiratory failure. A physician's order dated July 22, 2024, directed staff to weigh the resident every week on Mondays due to congestive heart failure and weight loss. There was no evidence that staff attempted to weigh the resident on July 29, 2024, and August 5, 12, and 19, 2024. In an interview on August 22, 2024, at 12:38 a.m., the Director of Nursing confirmed that there was no evidence that staff weighed the resident per physician's order. Clinical record review revealed that Resident 61 had diagnoses that included multiple sclerosis (damage to the nerves), quadriplegia (paralysis that affects all limbs of the body), neuromuscular dysfunction of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: Observation of the kitchen on October 11, 2023, at 9:05 a.m. revealed two bottles of thickened water with a use by date of August 2, 2023, and September 2, 2023. There were four bottles of thickened prune juice with use by dates of October 8, 2023, and two bottles of thickened prune juice with use by dates of September 25, 2023. There was an accumulation of a brown substance on the handle of the meat slicer. In the walk-in refrigerator, there were eight half gallons of milk with use by dates of October 6, 2023. In the second walk-in refrigerator, there was a container of pickles dated October 2, 2023, and a container of olives dated October 1, 2023. There was a tray of two boxes of raw bacon stored over ready to eat hard boiled eggs. In the reach-in refrigerator, there were three wrapped blocks of sliced cheese that were not in the original packaging and not labeled or dated. There was an unidentified food substance that was not in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to provide a comfortable, homelike environment for residents, staff and public on two of three nursing units. ([NAME] 3 and [NAME] 4) Findings include: Observation on October 11, 2023, at 10:22 a.m., revealed that the walls throughout the [NAME] 3 nursing unit were marred and scratched above and below the handrails, and the panels on the doors to resident rooms were also marred and scratched. The door jams to the main resident areas were marred and slightly damaged. Observations on October 11 and 12, 2023, at various times throughout the day, revealed that the lower half of the walls throughout the [NAME] 4 nursing unit were marred and scratched. The panels on the doors to resident rooms were marred, and the door jams to the main resident areas and the elevator doors had chipped paint and were slightly damaged. In room [ROOM NUMBER], the walls were marred and scratched. In room [ROOM NUMBER], there was exposed drywall with large areas of chipped…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation and staff interview, it was determined that the facility failed to provide services and treatment to prevent further limitations in range of motion for one of six sampled residents with limitations in range of motion. (Resident 72) Findings include: Clinical record review revealed that Resident 72 had diagnoses of hemiplegia, (paraplegia), of the left non-dominant side after a stroke, and dementia. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment, was totally dependent on staff for dressing, and had impairment in range of motion on both sides of her upper and lower extremities. Review of an occupational therapy screen dated July 17, 2023, revealed that the resident was to wear a left upper extremity comfy orthosis, (hand splint), when she was out of bed. A current physician order wad for the resident to wear a left upper extremity hand splint when she was out of bed. Observation on October 11, 2023, at 11:00 a.m., 1:07…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.