Health inspection·April 10, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of grievance forms, observations, staff interviews, review of two employee files, and policy review, the facility staff failed to implement their policy and provide appropriate and timely resolution to one resident's responsible family member's grievance concerning safe Hoyer transfers. This affected one (Resident #1) of five residents reviewed for grievances. The facility census was 61. Findings include: 1. Clinical record review for Resident #1 revealed an admission date of 12/30/22 with diagnoses including stroke, diabetes, aphasia, anxiety, and bi-polar disorder. He received hospice services since 05/10/24. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition and could not respond or be interviewed. Review of the care plan revised 11/20/23 revealed the resident was at high risk for falls and required staff total assistance for all activities of daily living including Hoyer transfers. Review of the Concern/Grievance forms revealed on 03/11/24, Resident #1's daughter sent Social Service (SS) #80 a text message requesting a sign be posted in the room that two staff were to operate the Hoyer lift for transfers; the information was reported to the Director of Nursing (DON). On 03/25/24, Resident #1's daughter sent a video recording to SS #80 of evening shift (7:00 P.M. to 7:00 A.M.) staff using a Hoyer lift with one staff member to transfer Resident #1; the information was shared with the management team. On 04/01/24, Resident #1's daughter sent a second video to SS #80 of evening shift staff using a Hoyer lift alone to transfer the resident; the nursing department was notified. On 04/02/24, the DON documented on a Concern/Grievance form that she observed the video of State Tested Nurse Aides (STNAs) using the Hoyer lift alone and spoke to Resident #1's daughter in the dining area. The DON would educate the staff and hang a sign in the room. On 04/09/24 at 1:10 P.M., the surveyor observed the two video recordings on SS #80's phone taken from a camera in Resident #1's room. The first recording received on 03/25/24 revealed the back of a dark skinned STNA transferring Resident #1 alone from his bed to his broda chair using a Hoyer lift. The second recording received on 04/01/24 revealed a different STNA wearing a mask transferring Resident #1 alone from his bed to his broda chair using a Hoyer life. At that time SS #80 verified she did not know the STNAs transferring the resident using a Hoyer lift alone. The surveyor observed the sign posted and signed by the DON in Resident #1's room that stated, Hoyers were to be used with two staff members. If I see or hear of staff using the Hoyer without assistants, I will terminate you no questions asked!!! (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 366236 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Village 422 North Burnett Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)