Inspection visit
Health inspection
28 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 28 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0567
Honor the resident's right to manage his or her financial affairs.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, facility list review, resident interview, staff interviews, and policy review,
the facility failed to ensure residents' personal funds were available in a timely manner. This had the
potential to affect 22 Residents (#2, #3, #4, #7, #11, #12, #13, #20, #22, #23, #24, #26, #37, #43, #46, #48,
#52, #53, #54, #56, #266, #367) of 22 identified to have personal fund accounts with the facility. The facility
census was 65.
Residents Affected - Some
Findings include:
Review of facility generated list of personal funds account revealed 22 Residents (#2, #3, #4, #7, #11, #12,
#13, #20, #22, #23, #24, #26, #37, #43, #46, #48, #52, #53, #54, #56, #266, #367) identified to have
personal fund accounts with the facility.
Review of Resident #7's medical record revealed an admission date of 12/30/22. Diagnoses include
anxiety, schizophrenia, hypothyroidism, major depressive disorder, Alzheimer's, heart failure, and kidney
disease.
Interview on 04/29/25 at 8:11 A.M., revealed a concern related to Resident #7 being able to access his
personal funds. Resident #7 shared that he is unable to withdrawal money on the weekend and has to wait
until Monday.
Interview on 04/30/25 at 3:10 P.M., with Business Office Manager #228 revealed the activities staff will ask
residents once a week if they would like to withdrawal funds. Funds are only available to residents Monday
through Friday and no one is in the facility to handle funds on the weekend.
Interview on 05/01/25 at 10:25 A.M., with Certified Nurse Aide #279 revealed on the weekends no one has
access to resident funds. Residents are required to wait until Monday when a manager is in the facility to
withdrawal their funds.
Review of the undated policy titled, Resident Funds Policy and Procedure revealed a resident request for
access to their funds will be honored the same for amounts less than $100 or amounts less than $50 for
Medicaid residents.
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 61
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
05/01/2025
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)
F 0576
Ensure residents have reasonable access to and privacy in their use of communication methods.
Level of Harm - Potential for
minimal harm
Based on resident interview, staff interview and policy review, the facility failed to ensure residents received
mail on the weekends. This had the potential to affect all 65 residents residing in the facility. The facility
census was 65.
Residents Affected - Many
Findings include:
Interview on 04/29/25 at 11:24 A.M., during resident group meeting, with Resident #1, #6, and #8, verified
the mail was not delivered on Saturday, only Monday through Friday.
Interview on 04/30/25 at 1:00 P.M., with Business Office Manager (BOM) #228 reported she would sort the
mail Monday through Friday, and then activities would pass mail to the residents. BOM #228 verified the
mail was not given to residents on Saturday, only Monday through Friday.
Review of the policy titled, Resident Rights Policy and Procedure, dated 2025, revealed each resident had
the right to send and receive mail, and to receive letters, packages, and other materials delivered to the
facility for the resident through a means other than a postal service and should comply with the state and
federal law.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 2 of 61
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
05/01/2025
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)
F 0605
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's
ability to function.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interview, the facility failed to ensure psychotropic medications were
ordered for an approved diagnosis. This affected one (#9) of five residents reviewed for unnecessary
medication. The facility census was 65.
Findings include:
Review of the medical record for Resident #9 revealed an admission date of 03/08/25. Diagnoses included
abdominal pain, spinal stenosis, gastritis and malnutrition.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had moderate
cognitive impairment with a Brief Interview Mental Status (BIMS) of 9.
Review of active physician orders dated 03/08/25 revealed an order for Aripiprazole oral tab 5 milligrams
(mg) once daily in morning (scheduled at 8:00 A.M.) was ordered for Hypotension. This medication is a
antipsychotic.
Interview on 05/01/25 at 8:42 A.M., with Regional Nurse #500 and Regional Nurse #508 confirmed
Ariprprazole (Abilify) was not used to treat hypotension and confirmed the order did not contain an
approved diagnosis. Also acknowledged Resident #9 had a pharmacy review and revealed this should have
been caught.
Interview on 05/01/25 at 9:00 A.M., with Director of Nursing revealed the hospital documentation had a
diagnosis of mood disorder and confirmed the facility did not have that diagnosis listed in the electronic
medical record.
Review of the undated policy titled, Pharmacy Services revealed the facility shall ensure the medication
was documented to treat a specific condition that was documented in the medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 3 of 61
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
05/01/2025
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)
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff and resident family interview, observation, and policy review, the facility failed to
implement the abuse policy for reporting and investigating an alleged injury of unknown origin. This affected
one (#55) of three residents reviewed for abuse. The census was 65.
Residents Affected - Few
Findings included:
Medical record review for Resident #55 revealed an admission date of 02/25/25. Her medical diagnoses
was multiple sclerosis (MS) and non-Alzheimer's dementia.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was
rarely or never understood. Her functional status was substantial/maximal assistance for eating, dependent
for toileting, bed mobility, and transfers were not attempted due to safety concerns. She used a Hoyer lift.
Review of the progress note dated 04/27/25 at 2:47 P.M., documented by Licensed Practical Nurse (LPN)
#249, revealed the family approached the nurse regarding a discoloration to resident's left leg. There was
bruising seen. The family stated she gets her leg caught on the Hoyer lift at times. The physician was
notified and a new order to watch for symptoms was initiated.
Interview on 04/28/25 at 12:06 P.M., with Resident #55's Family Member, reported Resident #55 had a dark
red bruise that wrapped around the lower left leg from the inside ankle to the calf and the ankle was
swollen. He stated it looked like hand prints to him.
Review of the progress notes written on 04/28/25 at 2:57 P.M., by the Director of Nursing (DON), revealed
she assessed the bruised area on Resident #55's area and the bruise lined up with the wheelchair and
resident crossing legs on the pedals. New intervention was to place a pillow on the foot pedals to prevent
further bruising. The area measured 6 centimeters (cm) by 5 cm by 0.1 cm and the husband was made
aware.
Interview on 04/29/25 at 2:00 P.M., with the DON revealed she didn't think she needed to file an injury of
unknown origin even though the resident was not able to tell her how the injury happened. The DON
reported she assessed the bruise but didn't have any documenting to support she did a couple of
interviews with anyone. She confirmed she didn't follow the abuse policy.
Interview on 04/29/25 at 2:12 P.M., with LPN #249, revealed the family of Resident #55 asked her to take a
look at a bruise on the resident's left leg. LPN #249 stated Certified Nursing Aides (CNA) #225 and #278
saw the area on 04/26/25 and it was reddened. LPN #249 reported when she looked at the area it had
some purple and light tent of red to the inside of the left ankle and up the back of the shin. The family stated
he thought it was the Hoyer lift because at times she will get her left leg caught in the lift if the staff doesn't'
move her left foot out of the way. She reported it made more sense it would be the Hoyer lift instead of the
resident resting her crossed legs on the pads of the wheelchair. LPN #249 reported if the bruise would have
been on the outside of the ankle then it could have been from the wheelchair. LPN #249 stated she called
the two CNAs (#225 and #278) and asked them if they hurt the resident while transferring her in the Hoyer
lift but they both denied it. She reported the bruise to the DON.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 4 of 61
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
05/01/2025
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)
F 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Observation on 04/29/25 at 2:20 P.M., of Resident #55 with the LPN #249, revealed the resident was sitting
in her wheelchair. She didn't have her legs crossed and her legs were dangling and she didn't have a pillow
to protect her legs from the wheelchair in place. The light bruising was on the inside of her left ankle and
ran up the calf to about 6 cm long. The resident wasn't able to answer any questions about the bruise.
When the nurse placed a pillow under her legs in the wheelchair the resident wasn't able to follow
commands about raising her legs and the nurse had to place the legs onto the pads of the wheelchair.
Interview on 04/29/25 at 2:30 P.M., with LPN #249 revealed she didn't know about the new intervention for
the pillow to placed under the resident's legs to protect her from the wheelchair.
Interview on 04/29/25 at 4:23 P.M., with CNA #225 revealed she saw the redness on the resident's leg on
04/26/25 and reported it to the nurse and they both assumed it happened in the wheelchair or in therapy.
Review of the undated policy titled Resident's Rights to Freedom from Abuse, Neglect and Exploitation
Policy and Procedure revealed to ensure a thorough investigation was conducted for the alleged violation.
The policy further revealed to ensure that all alleged violations involving abuse, neglect, exploitation or
mistreatment, including injuries of unknown source and misappropriation of resident property, are reported
in the proper time frame pursuant to this policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 5 of 61
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
05/01/2025
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff and resident family interview, observation, and policy review, the facility failed to
report an alleged injury of unknown origin. This affected one (#55) of three residents reviewed for abuse.
The census was 65.
Findings included:
Medical record review for Resident #55 revealed an admission date of 02/25/25. Her medical diagnoses
was multiple sclerosis (MS) and non-Alzheimer's dementia.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was
rarely or never understood. Her functional status was substantial/maximal assistance for eating, dependent
for toileting, bed mobility, and transfers were not attempted due to safety concerns. She used a Hoyer lift.
Review of the progress note dated 04/27/25 at 2:47 P.M., documented by Licensed Practical Nurse (LPN)
#249, revealed the family approached the nurse regarding a discoloration to resident's left leg. There was
bruising seen. The family stated she gets her leg caught on the Hoyer lift at times. The physician was
notified and a new order to watch for symptoms was initiated.
Interview on 04/28/25 at 12:06 P.M., with Resident #55's Family Member, reported Resident #55 had a dark
red bruise that wrapped around the lower left leg from the inside ankle to the calf and the ankle was
swollen. He stated it looked like hand prints to him.
Review of the progress notes written on 04/28/25 at 2:57 P.M., by the Director of Nursing (DON), revealed
she assessed the bruised area on Resident #55's area and the bruise lined up with the wheelchair and
resident crossing legs on the pedals. New intervention was to place a pillow on the foot pedals to prevent
further bruising. The area measured 6 centimeters (cm) by 5 cm by 0.1 cm and the husband was made
aware.
Interview on 04/29/25 at 2:00 P.M., with the DON revealed she didn't think she needed to file an injury of
unknown origin even though the resident was not able to tell her how the injury happened. The DON
reported she assessed the bruise but didn't have any documenting to support she did a couple of
interviews with anyone. She confirmed she didn't follow the abuse policy.
Interview on 04/29/25 at 2:12 P.M., with LPN #249, revealed the family of Resident #55 asked her to take a
look at a bruise on the resident's left leg. LPN #249 stated Certified Nursing Aides (CNA) #225 and #278
saw the area on 04/26/25 and it was reddened. LPN #249 reported when she looked at the area it had
some purple and light tent of red to the inside of the left ankle and up the back of the shin. The family stated
he thought it was the Hoyer lift because at times she will get her left leg caught in the lift if the staff doesn't'
move her left foot out of the way. She reported it made more sense it would be the Hoyer lift instead of the
resident resting her crossed legs on the pads of the wheelchair. LPN #249 reported if the bruise would have
been on the outside of the ankle then it could have been from the wheelchair. LPN #249 stated she called
the two CNAs (#225 and #278) and asked them if they hurt the resident while transferring her in the Hoyer
lift but they both denied it. She reported the bruise to the DON.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 6 of 61
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
05/01/2025
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Observation on 04/29/25 at 2:20 P.M., of Resident #55 with the LPN #249, revealed the resident was sitting
in her wheelchair. She didn't have her legs crossed and her legs were dangling and she didn't have a pillow
to protect her legs from the wheelchair in place. The light bruising was on the inside of her left ankle and
ran up the calf to about 6 cm long. The resident wasn't able to answer any questions about the bruise.
When the nurse placed a pillow under her legs in the wheelchair the resident wasn't able to follow
commands about raising her legs and the nurse had to place the legs onto the pads of the wheelchair.
Interview on 04/29/25 at 2:30 P.M., with LPN #249 revealed she didn't know about the new intervention for
the pillow to placed under the resident's legs to protect her from the wheelchair.
Interview on 04/29/25 at 4:23 P.M., with CNA #225 revealed she saw the redness on the resident's leg on
04/26/25 and reported it to the nurse and they both assumed it happened in the wheelchair or in therapy.
Review of the undated policy titled Resident's Rights to Freedom from Abuse, Neglect and Exploitation
Policy and Procedure revealed to ensure a thorough investigation was conducted for the alleged violation.
The policy further revealed to ensure that all alleged violations involving abuse, neglect, exploitation or
mistreatment, including injuries of unknown source and misappropriation of resident property, are reported
in the proper time frame pursuant to this policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 7 of 61
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
05/01/2025
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)
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff and resident family interview, observation, and policy review, the facility failed to
thoroughly investigate an alleged injury of unknown origin. This affected one (#55) of three residents
reviewed for abuse. The census was 65.
Residents Affected - Few
Findings included:
Medical record review for Resident #55 revealed an admission date of 02/25/25. Her medical diagnoses
was multiple sclerosis (MS) and non-Alzheimer's dementia.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was
rarely or never understood. Her functional status was substantial/maximal assistance for eating, dependent
for toileting, bed mobility, and transfers were not attempted due to safety concerns. She used a Hoyer lift.
Review of the progress note dated 04/27/25 at 2:47 P.M., documented by Licensed Practical Nurse (LPN)
#249, revealed the family approached the nurse regarding a discoloration to resident's left leg. There was
bruising seen. The family stated she gets her leg caught on the Hoyer lift at times. The physician was
notified and a new order to watch for symptoms was initiated.
Interview on 04/28/25 at 12:06 P.M., with Resident #55's Family Member, reported Resident #55 had a dark
red bruise that wrapped around the lower left leg from the inside ankle to the calf and the ankle was
swollen. He stated it looked like hand prints to him.
Review of the progress notes written on 04/28/25 at 2:57 P.M., by the Director of Nursing (DON), revealed
she assessed the bruised area on Resident #55's area and the bruise lined up with the wheelchair and
resident crossing legs on the pedals. New intervention was to place a pillow on the foot pedals to prevent
further bruising. The area measured 6 centimeters (cm) by 5 cm by 0.1 cm and the husband was made
aware.
Interview on 04/29/25 at 2:00 P.M., with the DON revealed she didn't think she needed to file an injury of
unknown origin even though the resident was not able to tell her how the injury happened. The DON
reported she assessed the bruise but didn't have any documenting to support she did a couple of
interviews with anyone. She confirmed she didn't follow the abuse policy.
Interview on 04/29/25 at 2:12 P.M., with LPN #249, revealed the family of Resident #55 asked her to take a
look at a bruise on the resident's left leg. LPN #249 stated Certified Nursing Aides (CNA) #225 and #278
saw the area on 04/26/25 and it was reddened. LPN #249 reported when she looked at the area it had
some purple and light tent of red to the inside of the left ankle and up the back of the shin. The family stated
he thought it was the Hoyer lift because at times she will get her left leg caught in the lift if the staff doesn't'
move her left foot out of the way. She reported it made more sense it would be the Hoyer lift instead of the
resident resting her crossed legs on the pads of the wheelchair. LPN #249 reported if the bruise would have
been on the outside of the ankle then it could have been from the wheelchair. LPN #249 stated she called
the two CNAs (#225 and #278) and asked them if they hurt the resident while transferring her in the Hoyer
lift but they both denied it. She reported the bruise to the DON.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 8 of 61
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
05/01/2025
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)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Observation on 04/29/25 at 2:20 P.M., of Resident #55 with the LPN #249, revealed the resident was sitting
in her wheelchair. She didn't have her legs crossed and her legs were dangling and she didn't have a pillow
to protect her legs from the wheelchair in place. The light bruising was on the inside of her left ankle and
ran up the calf to about 6 cm long. The resident wasn't able to answer any questions about the bruise.
When the nurse placed a pillow under her legs in the wheelchair the resident wasn't able to follow
commands about raising her legs and the nurse had to place the legs onto the pads of the wheelchair.
Interview on 04/29/25 at 2:30 P.M., with LPN #249 revealed she didn't know about the new intervention for
the pillow to placed under the resident's legs to protect her from the wheelchair.
Interview on 04/29/25 at 4:23 P.M., with CNA #225 revealed she saw the redness on the resident's leg on
04/26/25 and reported it to the nurse and they both assumed it happened in the wheelchair or in therapy.
Review of the undated policy titled Resident's Rights to Freedom from Abuse, Neglect and Exploitation
Policy and Procedure revealed all alleged violations involving abuse, neglect, exploitation or mistreatment,
including injuries of unknown source and misappropriation of resident property, ensure a thorough
investigation is conducted for the alleged violation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 9 of 61
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
05/01/2025
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the medical records and staff interviews, the facility failed to develop care plans to meet the needs
of the residents. This affected four (#30, #36, #266, and #366) of 24 residents reviewed for care plans. The
facility census was 65.
Findings include:
1. Review of the medical record for Resident #36 revealed an admission date of 08/25/23. Diagnoses
included dementia, major depressive disorder, and anxiety disorder.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had
severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three. This
resident was assessed to require setup with eating, supervision with toileting, bathing, dressing, and
transfers.
Review of the physician order dated 03/12/25 revealed Resident #36 was ordered Ativan 0.5 milligrams
(mg), give one tablet by mouth two times a day for anxiety.
Review of the care plan for Resident #36 revealed she did not have a care plan for psychotropic
medications relating to anxiety medication.
Interview on 05/01/25 at 11:00 A.M., with MDS Nurse #501 verified Resident #36 did not have a care plan
created for anxiety medications.
2. Review of the medical record for Resident #266 revealed an admission date of 01/06/23. Diagnoses
included Alzheimer's disease, Parkinson's disease, anxiety disorder, and type two diabetes mellitus (DM II).
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #266 had
moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of nine.
This resident was assessed to require independent with eating, partial assistance with toileting and
transfers, dependent with bathing, and substantial assistance with dressing.
Review of the physician order dated 03/17/25 revealed Resident #266 was ordered catheter care every
shift.
Interview on 04/30/25 at 2:51 P.M., with MDS Nurse #501 verified Resident #366 did not have a care plan
created for the use of urinary catheter.
3. Review of the medical record for Resident #366 revealed an admission date of 02/19/25 with a discharge
date of 03/28/25. Diagnoses included cellulitis, chronic kidney disease stage three, type two diabetes
mellitus (DM II), and unstageable pressure ulcer of right heel.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #366 had
intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. This resident was
assessed to require setup with eating, dependent with toileting, and substantial assistance
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 10 of 61
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
05/01/2025
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)
F 0656
with bathing, dressing, and transfers.
Level of Harm - Minimal harm
or potential for actual harm
Review of section M of the admission MDS dated [DATE] revealed Resident #366 had eight venous and
arterial ulcers present.
Residents Affected - Some
Review of the care plan for Resident #366 revealed she had no care plan for impaired skin integrity.
Interview on 04/30/25 at 2:51 P.M., with MDS Nurse #501 verified Resident #366 did not have a care plan
created for skin impairment.
4. Review of Resident #30's medical record revealed an admission date on 08/13/24. Diagnoses included
chronic obstructive pulmonary disease (COPD), congestive heart failure, hypertension, hemiplegia,
hyperlipidema, and protein-calorie malnutrition.
Review of the MDS assessment dated [DATE] revealed the Resident #30 was cognitively intact.
Review of Resident #30's medical record revealed the resident was accepted by hospice on 01/15/25 for
diagnosis of COPD.
Review of Resident #30's care plan on 05/01/25 found no evidence of the resident being on hospice
included in the care plan.
Interview on 05/01/25 at 11:13 A.M., with the Director of Nursing verified Resident #30 did not have a care
plan in place for hospice service.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 11 of 61
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
05/01/2025
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)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, resident interviews, family interviews, staff interviews, and policy review, the facility
failed to ensure care conferences were completed quarterly and the interdisciplinary team was present for
five (#7, #13, #16, #26, and #55) of five residents reviewed for care conferences. The facility also failed to
ensure revisions of care plans were updated for six (#7, #18, #30, #33, #51 and #62) of 24 care plans
reviewed during the annual survey. The facility census was 65.
Findings included:
1. Medical record review for Resident #7 revealed an admission date of 12/30/22. His medical diagnoses
included arteriosclerotic heart disease, schizophrenia, Alzheimer's, diabetes, chronic kidney disease, and
convulsions.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was severely
cognitively impaired. His functional status was setup or clean-up assistance for eating, substantial/maximal
assistance for toileting, supervision or touching assistance for bed mobility and transfers. He was always
incontinent for bladder and codes for a colostomy. He was coded for wandering.
a. Review of the care conferences since 01/02/24 revealed Resident #7 had one meeting on 01/02/24.
There wasn't any notes on the care conference paperwork. The paperwork said to look at the progress note
for 01/02/24 but there was no progress notes for this day regarding the care conference.
Interview on 04/29/25 at 8:13 A.M., with Resident #7's Family Member revealed they were having care
conference quarterly and then they stopped.
Interview on 04/30/25 at 2:17 P.M., with the Social Worker Designee (SWD) #263 confirmed there had only
been one care conference for Resident #7 on 01/02/24.
b. Review of the care plan dated 01/23/24 revealed Resident #7 was at risk for elopement. Intervention
initiated on 09/18/24 revealed 15-minute checks. Review of the 15-minute checks forms revealed they were
discontinued on 09/19/24.
Interview on 04/30/25 at 8:54 A.M., with MDS Nurse #501 confirmed the care plan should have been
updated to reflect the resident was no longer on 15-minute checks.
2. Medical record review for Resident #55 revealed an admission date of 02/25/25. Her medical diagnoses
was Multiple Sclerosis (MS) and non-Alzheimer's dementia.
Review of the admission MDS dated [DATE] revealed Resident #55 was rarely or never understood. Her
functional status was substantial/maximal assistance for eating, dependent for toileting, bed mobility, and
transfers were not attempted due to safety concerns. She used a Hoyer lift.
Review of care conferences for Resident #55 since 02/25/25 revealed one on 03/25/25 and there was one
signature on the form.
Interview on 04/28/25 at 12:15 P.M., revealed Resident #55's Family Member stated they did not have
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 12 of 61
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
05/01/2025
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)
F 0657
a care conference upon admission and not until a month after admission.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 04/30/25 at 2:17 P.M., with the Social Worker Designee (SWD) #263 confirmed there was not
a care conference upon admission and there was not members of the disciplinary team present for the
meeting for Resident #55.
Residents Affected - Some
9. Review of medical record for Resident #62 revealed admission date of 9/13/24. The resident was
currently receiving hospice services and had been admitted with diagnoses including alcohol dependence
with alcohol induced persisting dementia, anxiety, unspecified dementia with unspecified severity with
agitation.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he severely impaired
cognition. He was dependent on all Activities of Daily Living. No falls were documented in look back.
Review of the care plan a risk for falls related to gait and balance problems, poor communication and
unawareness of safety needs. Interventions included to use mechanical lift to move to a safe location to
prevent falls.
Interview on 04/28/25 at 9:37 A.M., with Certified Nursing Assistant (CNA) #242 revealed she was
scheduled for one-on-one care for Resident #62 due to his wanderings and falls.
Interview on 04/30/25 at 10:38 A.M., with MDS Nurse #501 acknowledged Resident #62's care plan had
not been updated to reflect he no longer required a mechanical lift, he required one to one supervision for
safety and did not contain an updated hospice care plan.
3. Review of the medical record for Resident #13 revealed an admission date of 10/25/22. Diagnoses
included cerebral infarction, diabetes mellitus, hemiplegia and hemiparesis affecting right dominant side,
and chronic obstructive pulmonary disease (COPD).
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had
moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This
resident was assessed to require setup with eating, substantial assistance with toileting, bathing, and
transfers, and dependent with dressing.
Review of the care conferences for the last 12 months for Resident #13 revealed attempted meetings on
06/04/24, 02/14/25, and 03/10/25 because Resident #13's daughter did not show.
Interview on 04/30/25 at 9:00 A.M., with SWD #263 verified care conferences were to be completed
quarterly. SWD #263 verified Resident #13 did not have care conferences completed quarterly as required.
4. Review of the medical record for Resident #26 revealed an admission date of 08/26/24. Diagnoses
included major depressive disorder, schizoaffective disorder, and generalized anxiety disorder (GAD).
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had
severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. This
resident was assessed to require setup with eating, partial assistance with toileting, bathing,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 13 of 61
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
05/01/2025
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)
F 0657
supervision with dressing and transfers.
Level of Harm - Minimal harm
or potential for actual harm
Review of the care conferences for the last 12 months for Resident #26 revealed a care conference was
completed on 03/12/24 and 06/25/24.
Residents Affected - Some
Interview on 04/30/25 at 9:00 A.M., with SWD #263 verified care conferences were to be completed
quarterly. SWD #263 verified Resident #26 did not have care conferences completed quarterly as required.
10. Review of the medical record for Resident #33 revealed an admission date of 09/19/24. Medical
diagnoses included sepsis and diabetes mellitus.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively
impaired. Her functional status was dependent for eating, oral hygiene, toileting, bathing, dressing, and
positioning in bed.
Review of Resident #33 medical records revealed she was hospitalized [DATE] through 02/03/25.
Review of wound documentation notes dated 02/07/25 revealed Resident #33 had the following skin
impairments an unstageable wound on her right gluteal fold, an unstageable wound on her right buttock,
Stage 4 pressure ulcer on her sacrum and left ischium, a Stage 3 pressure ulcer to her left posterior thigh
and left buttocks, and a deep pressure injury (DTI) to her right heel.
Review of the care plan dated 10/22/24, revised 01/14/25, for Resident #33 revealed the resident had a
stage 3 pressure ulcer on her left buttock, a stage 4 pressure ulcer on her left ischium, a stage 4 pressure
ulcer on her sacrum, and a DTI on her right heel. Care plan for Resident #33 revealed interventions
included to administer treatments as ordered and monitor for effectiveness. Air mattress to bed at all times
due to wounds. Educate staff to ensure heel/moon boots were on and heels were floated. Follow facility
policies and protocols for the prevention and treatment of skin breakdown. Monitor dressing to ensure it is
intact and adhering, report lose dressing to treatment nurse.
Review of care plan for Resident #33 revealed there was no documentation or interventions in place for
Resident #33 wound on her left posterior thigh, right buttock, or right gluteal fold.
Interview on 04/30/25 at 8:54 A.M., with MDS nurse #501 confirmed the care plan was not updated to
include the current skin impairments.
Review of the undated policy titled Comprehensive Person-Centered Care Planning Policy and Procedure
revealed the care plans would be reviewed and revised by the interdisciplinary team after each
assessment, including both the comprehensive and quarterly review assessments.
Collaboration will be an emphasis on partnering between residents and/or his or her representative, and all
staff and disciplines involved in the resident's care in developing the plan of care. There is recognition that
healing
happens in relationships and in the meaningful sharing of power and decision-making.
Empowerment, voice, and choice - Ensuring that the resident's choice and preferences are honored and
that residents are empowered to be active participants in their care and decision-making,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 14 of 61
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
05/01/2025
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)
F 0657
including recognition of, and building on each resident's strengths.
Level of Harm - Minimal harm
or potential for actual harm
Comprehensive Care Plans.
1.
Residents Affected - Some
The Facility will develop and implement a comprehensive person-centered care plan for each resident,
consistent with the resident rights set forth under the law that includes measurable objectives and
timeframe's to meet each resident's medical, nursing, and mental and psychological needs that are
identified in the comprehensive assessment.
2.
The comprehensive care plan will describe the following:
a.
The services that are to be furnished to attain or maintain the resident's highest practicable physical,
mental, and psychological well-being as required under law; and
b.
Any services that would otherwise be required under law or regulation but are not provided due to the
resident's exercise of rights, including the resident's right to refuse treatment.
3.
The comprehensive care plan shall be:
a.
Developed within 7 days after completion of the comprehensive assessment.
Interview with MDS Nurse #501 on 05/01/25 at 10:15 A.M. verified that if there are new skin issues she
should be updated, and the care plan should be updated at that time.
5. Review of Resident #16's medical record revealed an admission date of 02/07/25. Diagnoses included
coronary artery disease, hypertension, diabetes mellitus, hyperlipidemia, thyroid disorder, seizure disorder,
anxiety, and depression.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident #16 was cognitively
intact.
Review of the care conference dated 02/20/25 revealed that attendees for the conference were Licensed
Practical Nurse #213 and a family member of Resident #16. The care conference was coordinated by the
SWD #263. Further review of the care conference form revealed that no comments of what was discussed
during the conference were include on the form.
Interview on 04/30/25 at 2:13 P.M., with the SWD #263 verified the comment section of the care
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 15 of 61
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
05/01/2025
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)
F 0657
conference form was blank.
Level of Harm - Minimal harm
or potential for actual harm
6. Review of Resident #51's medical record revealed an admission date of 02/07/25. Diagnoses include
congestive heart failure, hypertension, diabetes mellitus, and hyperlipidemia.
Residents Affected - Some
Review of the MDS assessment dated [DATE] revealed resident #51 was cognitively intact.
Further review of Resident #51's medical record revealed Resident #51 has an active order from 02/10/25
requiring blood sugar checks to be completed before each meal and at bed time. The order includes the
physician must be contacted if blood sugar levels are less than 70 or more than 250.
Review of the care plan for Resident #51 on 04/30/25 revealed the blood sugar checks and contacting the
physician if levels were below 70 or above 250 were not included in the care plan.
Interview on 04/30/25 at 10:42 A.M., with MDS Nurse #501 confirmed that blood sugar checks should be
added to a care plan for a resident with orders to monitor blood sugar levels.
7. Review of Resident #18's medical record revealed an admission date of 05/07/24. Diagnoses include
anemia, hypertension, hyperlipidemia, Alzheimer's, dementia, and depression.
Review of the MDS assessment dated [DATE] revealed resident #18 is cognitively impaired.
Review of Resident #18's progress note date 10/08/24 revealed a house nutritional supplement of 237
milliliters (ml) once a day was ordered.
Review of Resident #18's progress note dated 01/10/25 revealed weekly weights were ordered.
Review of Resident #18's nutritional assessment dated [DATE] revealed a recommendation to initiate
weekly weights and increase the house nutritional supplement to 237 ml twice a day.
Review of Resident 18's care plan on 04/30/25 revealed weekly weights and nutritional supplements were
not added to the nutrition care plan.
Interview on 04/30/25 at approximately 5:00 P.M., with the Director of Nursing (DON) verified Resident
#18's care plan was not revised with the order for weekly weights or interventions.
8. Review of Resident #30's medical record revealed Resident #30 was admitted to the facility on [DATE].
Diagnoses included acute and chronic respiratory failure, chronic pulmonary disease, peripheral vascular
disease, hypertension, hemiplegia, hyperlipidemia, and protein-calorie malnutrition.
Review of Resident #30's MDS assessment dated [DATE] revealed the resident was cognitively intact.
Review of Residents #30's medical record on 05/01/25 revealed that Resident #30 had an advanced
directive for DNR Comfort Care dated 01/18/25.
Review of Resident #30's care plan on 05/01/25 revealed that Resident #30's advance directive was listed
for a full code.
Interview on 05/01/25 at 11:13 A.M., with the DON verified the advanced directive in Resident #30's
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 16 of 61
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
05/01/2025
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)
F 0657
care plan was not revised after the DNR Comfort Care was signed.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 17 of 61
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
05/01/2025
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)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff and family interview, and policy review, the facility failed to ensure
a resident dependent on staff for assistance with activities of daily living was provided oral hygiene. This
affected one (#55) of five residents reviewed for Activities of Daily Living (ADL). The facility census was 65.
Residents Affected - Few
Findings included:
Medical record review for Resident #55 revealed an admission date of 02/25/25. Her medical diagnoses
was Multiple Sclerosis (MS) and non-Alzheimer's dementia.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was
rarely or never understood. Her functional status was substantial/maximal assistance for eating, dependent
for toileting, bed mobility, and transfers were not attempted due to safety concerns. She used a Hoyer lift.
Review of care plan dated 03/05/25 revealed Resident #55 was at risk for poor oral hygiene. Her
intervention was to provide mouth care as per the ADL personal hygiene.
Interview on 04/28/25 at 12:16 P.M., with Resident #55's Family Member revealed she wasn't getting her
teeth brushed like she should be. He further revealed the resident brushed her teeth after every meal when
she lived at home. Observation at the same time as the interview revealed Resident #55's teeth had a
yellow film on them.
Observation on 04/29/25 at 9:30 A.M. revealed Registered Nurse (RN) #285 was feeding Resident #55's
breakfast to her.
Interview on 04/29/25 at 4:40 P.M., with RN #285 revealed she didn't brush Resident #55's teeth after
breakfast.
Interview on 04/30/25 at 3:14 P.M., with Certified Nursing Aide (CNA) #204 revealed she fed the resident
breakfast and lunch but didn't brush her teeth after the meals. She reported the teeth brushing was
supposed to be after meals.
Review of the medical record for the date of 04/30/25 revealed no documentation of the teeth were not
brushed after breakfast or lunch for Resident #55.
Review of the policy titled, Activities of Daily Living, dated 03/01/18, revealed residents who are unable to
carry out ADL's independently will receive the services necessary to maintain good nutrition, grooming and
personal and oral hygiene.
This deficiency represents the noncompliance investigated under Complaint Numbers OH00164520 and
OH00164238.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 18 of 61
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
05/01/2025
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)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, review of physician orders, staff interviews, Certified Nursing Practitioner interview,
and review of policy, the facility failed to ensure physician orders were clarified when to contact the
physician for a resident daily weight change for Resident #41. The facility failed to physician orders were
followed to obtain blood sugars and contact the physician when blood sugars were out of the parameters
for Resident #51. The facility failed to ensure coordination with hospice services were established for
hospice care for Resident #30. The facility failed to ensure skin assessments and treatments were
completed for Resident #13. This affected four (#13, #30, #41 and #51) of 24 residents records reviewed for
quality of care . The facility census was 65.
Residents Affected - Some
Findings include:
1. Review of medical record for Resident #41 revealed admission date of 01/09/23, with diagnoses
including major depressive disorder, alcohol abuse, chronic viral hepatitis, anxiety and alcohol dependence.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview
Mental Status (BIMS) score of 14, indicating intact cognition. He was independent for Activities of Daily
Living.
Review of the plan of care revealed a care plan for fluid overload or a potential for fluid volume overload
related to the diagnosis of Hepatitis C. Interventions included to provide medications as ordered and to
monitor, document and report any signs or symptoms of fluid overload.
Review of the 04/17/25 physician note revealed Resident #41 had been seen due to pulmonary congestion
on a recent chest x-ray with increased dyspnea (feeling short of breath) over a few days. The plan was to
give Lasix (diuretic) 40 milligrams (mg) once and then reduce Lasix to 20 mg and daily weights for two
weeks.
Review of the daily weights from 04/18/25 through 04/28/25 revealed the weight on 04/20/25 was 225.5
pounds, on 04/21/25 was 228 pounds, on 04/26/25 was 226 pounds, and on 04/27/25 was 228 pounds.
Interview on 04/30/25 at 9:21 A.M. , with Licensed Practical Nurse (LPN) #213 revealed she was unaware
Resident #41 was getting daily weights and thought it may have been ordered by the dietician for nutrition.
Interview on 04/30/25 at 9:55 A.M., with the Director of Nursing revealed Resident #41 had been ordered
daily weights due to a recent chest X-Ray which had showed chest congestion, she shared he had
received Lasix to remove fluid. She acknowledged staff did not clarify when the physician wanted notified
for a weight change.
Interview on 04/30/25 at 10:38 A.M., with Certified Nurse Practitioner (CNP) #502 revealed Resident #41
had a recent Chest X-ray which revealed Pulmonary congestion, he had ordered Lasix to remove excess
fluid and daily weights to monitor fluid changes. He shared it was his expectation the nursing staff would be
knowledgeable to know to contact him with a two pound weight gain overnight or five pounds in a week. He
verified he had not been informed of the 04/21/25 or 04/27/25 weight gain.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 19 of 61
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
05/01/2025
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
4. Review of the medical record for Resident #13 revealed an admission date of 10/25/22. Diagnoses
included cerebral infarction, diabetes mellitus, hemiplegia and hemiparesis affecting right dominant side,
and chronic obstructive pulmonary disease (COPD).
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had
moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This
resident was assessed to require setup with eating, substantial assistance with toileting, bathing, and
transfers, and dependent with dressing.
Review of the care plan dated 06/13/24 revealed Resident #13 had potential impairment to skin integrity
related to need for assistance with incontinence and right sided hemiplegia. Interventions included avoid
scratching and keep hands from excessive moisture, encourage good nutrition and hydration, keep skin
clean and dry, provide treatment to any moisture associated skin damage (MASD) that flared up, and use
draw sheet or lifting device to move her.
Review of the progress note dated 02/17/25 at 6:49 P.M., revealed Resident #13 had an open lesion to the
right gluteal fold that was acquired in-house. No measurements were completed.
Review of the progress note dated 02/26/25 at 2:36 A.M., revealed Resident #13 had open lesion to the
right gluteal fold. Area had gotten worse. Education provided to change positions every two hours and apply
moisture barrier cream.
Review of the progress note date 02/27/25 at 5:13 P.M., revealed Resident #13 had a new area to the left
iliac crest related to moisture associated skin damage (MASD) that was acquired in-house.
Review of the physician order dated 03/01/25 revealed Resident #13 was ordered to cleanse area to right
buttock with soap and water. Apply medihoney and border foam dressing daily and as needed every day
shift.
Review of the medical record revealed Resident #13 was never seen by the wound care team after two new
areas developed in-house.
Review of the weekly skin assessments dated 04/10/25 and 04/24/25 for Resident #13 revealed the
assessment was incomplete.
Interview on 05/01/25 at 8:51 A.M. with Assistant Director of Nursing (ADON) verified inconsistencies and
completion of weekly skin assessments on Resident #13. ADON stated a referral should have been
completed in February when Resident #13 had a new open lesion to the right gluteal fold.
Review of the facility policy titled, Wound Care, revised 2010 revealed the purpose of the procedure was to
provide guidelines for the care of wounds to promote healing. The follow information should be recorded in
the resident's medical record: the type of wound care given, the date and time wound care was given, the
position in which the resident was placed, the name and title of the individual performing the wound care,
any change in the resident's condition, all assessment data (wound bed color, size, drainage, etc.) obtained
when inspecting the wound, how the resident tolerated the procedure, if the resident refused treatment, and
the signature of the person recording the data.
This deficiency represents the noncompliance investigated under Complaint Numbers OH00164520 and
OH00164238.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 20 of 61
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
05/01/2025
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
2. Review of Resident #51's medical record revealed an admission date of 02/07/25. Diagnoses include
congestive heart failure, hypertension, diabetes mellitus, and hyperlipidemia.
Review of the MDS assessment dated [DATE] revealed resident #51 was cognitively intact.
Further review of Resident #51's active physician order dated 02/10/25 requiring blood sugar checks to be
completed before each meal and at bed time. The order includes that the physician must be contacted if
blood sugar levels are less than 70 or more than 250.
Review of Resident #51's vitals summary sheet for February 2025 revealed missing blood sugar checks on
02/12/25, 02/18/25, 02/19/25, 02/20/25, 02/21/25, 02/22/35, 02/23/25, 02/26/25, 02/27/25, and 02/28/25.
Further review revealed that blood sugar levels were not documented for the entire day on 02/21/25 and
02/28/25.
Review of Resident #51's vitals summary sheet for March 2025 revealed missing blood sugar checks each
day for the entire month of March. Further review revealed that blood sugar levels were not documented for
the entire day on 03/04/25, 03/11/25, 03/14/25, 03/18/25, 03/24/25, and 03/28/25.
Review of Resident #51's vitals summary for April 2025 revealed missing blood sugar check on days
04/01/25-04/12/25. Further review revealed that blood sugar levels were not documented for the entire day
on 04/02/25, 04/03/25, 04/06/25, and 04/08/25.
Further review of Resident #51's vitals summary revealed that Resident #51 experienced blood sugar levels
more than 250 on 02/11/25 (345), 02/12/25 (456 and 472), 02/15/25 (252, 399 and 386), 02/24/25 (253),
02/26/25 (271), 03/07/25 (456), 03/08/25 (274), 03/09/25 (285), 03/15/25 (360), 03/21/25 (336), 03/22/25
(400), 03/23/25 (256), 03/25/25 (289), 03/26/25 (289 and 255), 03/29/25 (306), 03/30/25 (426), 03/31/25
(350), 04/01/25 (417), 04/04/25 (417 and 302), 04/04/25 (300), 04/11/25 (357 and 254), 04/12/15 (399, 302
and 488), 04/13/25 (298, 311, 301 and 554), 04/14/25 (422, 308, and 301), 04/15/25 (278, 310, and 422),
04/18/25 (327, 307, 387, and 449), 04/21/25 (409), 04/22/25 (588, 299, and 289), 04/24/25 (368), 04/25/25
(485, 334, and 450), 04/27/25 (272 and 292), 04/28/25 (381), 04/29/25 (261), 04/29/25 (372), 04/30/25
(311) and 05/01/25 (330).
Review of Resident #51's medical record revealed the physician was only notified of Resident #51's blood
sugar levels over 250 on 03/01/25 and 03/05/25.
Interview on 04/30/25 at approximately 10:00 A.M., with the Director of Nursing (DON), verified that
Resident #51 did not have their blood sugars monitored as ordered by the physician. DON also verified that
Resident #51's physician was only notified on 03/01/25 and 03/05/25.
Interview on 04/30/25 at 10:39 A.M., with Nurse Practitioner (NP) #502, verified that a physician should be
contacted if a patient is experiencing blood sugars over 250. NP #502 confirmed if he was notified of
Resident #51's blood sugar levels, he would have ordered a sliding scale insulin to help the Resident #51
manage their blood sugar levels.
Review of Resident #51's medical record on 05/01/25 revealed no current orders for insulin sliding scale
coverage.
3. Review of Resident #30's medical record revealed Resident #30 was admitted to the facility on [DATE].
Diagnoses included acute and chronic respiratory failure, chronic pulmonary disease,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 21 of 61
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
05/01/2025
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
peripheral vascular disease, hypertension, hemiplegia, hyperlipidemia, and protein-calorie malnutrition.
Resident #30 was accepted by hospice on 01/15/25
Review of Resident #30's MDS assessment dated [DATE] revealed the resident was cognitively intact.
Interview on 05/01/25 at 9:00 A.M., with Registered Nurse (RN) #240, verified the binders are kept at each
nurses station with hospice information for each resident on hospice. RN #240 was asked for the binder
that included hospice information for Resident #30. RN #240 verified she could not locate Resident #30's
hospice information in the binders.
Interview on 05/01/25 at 11:13 A.M., with DON, verified the facility does not have any documentation of
communication or a care plan from hospice for Resident #30.
Review of the undated policy titled, Hospice Program revealed when a resident participates in the hospice
program, a coordinated plan of care between the facility, hospice agency and resident/family will be
developed and shall include directives for managing pain and other uncomfortable symptoms. The care
plan shall be revised and updated as necessary to reflect the resident's current status.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 22 of 61
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
05/01/2025
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)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and policy review, the facility failed to ensure completion of physician
ordered treatments to promote wound healing. This affected one (#33) of three residents reviewed for
pressure ulcers. The facility census was 65.
Residents Affected - Few
Findings include:
Medical record review for Resident #33 revealed an admission date of 09/19/24. Medical diagnoses
included sepsis and diabetes mellitus.
Review of the care plan dated 10/22/24 for Resident #33 revealed the resident had the potential for
pressure ulcers. Interventions were to administer treatments as orders and monitor for effectiveness.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was
cognitively impaired. Her functional status was dependent for eating, oral hygiene, toileting, bathing,
dressing, and positioning in bed.
Review of the physician's orders dated 03/25/25 revealed an order for the left buttock: cleanse with wound
cleanser, apply hydrogel, calcium alginate, cover with border foam dressing every shift for skin integrity.
Review of the physician's orders dated 03/25/25 revealed an order for the right buttock: cleanse with wound
cleanser, apply hydrogel, calcium alginate, cover with border foam dressing every shift for skin integrity.
Review of the physician's orders dated 03/25/25 revealed an order for the right gluteal fold: cleanse with
wound cleanser, apply hydrogel, calcium alginate, cover with border foam every shift for skin integrity.
Review of the physician's orders dated 03/25/25 revealed an order for the right heel: cleanse with wound
cleanser, pay dry, apply skin prep, leave open to air, heel boot for offloading every shift for skin integrity.
Review of the physician's orders dated 03/26/25 revealed and order for the left posterior upper thigh:
cleanse with wound cleanser, apply hydrogel, calcium alginate, cover with border gauze every day shift for
skin integrity. These were missed on 04/11/25, 04/16/25, and 04/21/25.
Review of the physician's orders dated 04/21/25 revealed for the sacrum: cleanse sacrum with wound
cleanser, pat dry, cover with calcium alginate, cover with sacral border foam. Change twice daily and as
needed for wound care.
Review of the treatment administration record (TAR) from 04/01/25 through 04/30/25 revealed the all the
treatments were blank for documentation of the completion on 04/11/25, 04/16/25, 04/21/25, and 04/25/25.
Interview on 04/30/25 at 2:20 P.M., with the Director of Nursing (DON) confirmed no evidence of the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 23 of 61
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
05/01/2025
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)
F 0686
treatments being completed for the listed dates.
Level of Harm - Minimal harm
or potential for actual harm
Review of the policy entitled Wound Care dated 2001, revised October 2010, revealed the following:
The following information should be recorded in the resident's medical record:
Residents Affected - Few
1. The type of wound care given.
2. The date and time the wound care was given.
3. The position in which the resident was placed.
4. The name and title of the individual performing the wound care.
5. Any change in the resident's condition.
6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.
7. How the resident tolerated the procedure.
8. Any problems or complaints made by the resident related to the procedure
9. If the resident refused the treatment and the reason(s) why.
10. The signature and title of the person recording the data.
This deficiency represents the noncompliance investigated under Complaint Numbers OH00164520 and
OH00164238.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 24 of 61
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
05/01/2025
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, medical record review, staff and resident interviews, and policy review, the facility failed to
ensure safe water temperatures in resident rooms. This affected five (#18, #37, #51, #59, and #60) of five
residents reviewed for water temperatures. The facility failed to ensure safe smoking parameters were in
place for one (#20) of one resident reviewed for smoking. The facility census was 65.
Findings include
Observation on 04/28/25 at 10:20 A.M., revealed water temperatures of 144 degrees Fahrenheit (F) for the
shared bathroom for Residents #18, #37, #51 and #60 had hot water temperatures.
1. Review of the medical record for Resident #51 revealed an admission date of 02/07/25. Diagnoses
included shortness of breath, diabetes, and heart failure.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was cognitively
intact with a Brief Interview Mental Status (BIMS) of 15 and required supervision or touching assistance
with toileting.
2. Review of the medical record for Resident #18 revealed an admission date of 05/07/24. Diagnoses
included dementia, Alzheimer's disease, and cognitive communication deficit.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively
impaired with a Brief Interview Mental Status (BIMS) stating resident was rarely/never understood and
required supervision or touching assistance with toileting.
3. Review of the medical record for Resident #60 revealed an admission date of 04/01/24. Diagnoses
included ataxia, dyspnea, edema and weakness.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was cognitively
intact with a Brief Interview Mental Status (BIMS) of 13 and required partial/moderate assistance with
toileting.
4. Review of the medical record for Resident #37 revealed an admission date of 12/31/20. Diagnoses
included myocardial infarction, hemiplegia and hemiparesis, cerebral infarct, heart disease, and vascular
dementia.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was significant
cognitively impairment with a Brief Interview Mental Status (BIMS) of 00 and required partial/moderate
assistance for toileting.
Observation on 04/28/25 at 1:10 P.M., with Maintenance Director (MD) #300, who took the temperature of
the bathroom sink water and registered at 144.1 degrees F.
Interview at the time of the observation, with MD #300, confirmed the water temperature was too high and
should be around 120 degrees F. MD #300 stated the hot water tank for this room was connected to the
kitchen and was high due to the dishwasher. MD #300 verified steam was coming from the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 25 of 61
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
05/01/2025
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)
F 0689
faucet.
Level of Harm - Minimal harm
or potential for actual harm
5. Review of the medical record for Resident #59 revealed an admission date of 06/24/24. Diagnoses
included mood disorder, psychosis, traumatic brain injury, and violent behavior.
Residents Affected - Some
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was significant
cognitive impairment with a Brief Interview Mental Status (BIMS) of 03 and was independent toileting.
Observation on 04/28/25 at 1:15 P.M., with MD #300 and Resident #59, revealed MD #300 took the
temperature of the bathroom sink water for Resident #59 and the water registered at 141.9 degrees F. MD
#300 confirmed this was too high and should be around 120 degrees F. MD #300 stated the hot water tank
for this room was connected to the kitchen and was high due to the dishwasher. Resident #59 reported the
sink water gets very hot.
Review of the policy titled, Water Temperatures - Safety, dated 05/10/20 revealed the policy was related
more to food service areas but included a chart stating risk of third degree burns occur at 140 degrees F in
five seconds and at 148 degrees F at one second.
6. Review of medical record for Resident #20 revealed admission date of 10/02/23. The resident was
admitted with diagnoses including Chronic Obstructive Pulmonary Disease, bladder cancer, unspecified
dementia, and peripheral vascular disease.
Review the quarterly Minimum Data Set (MDS) dated [DATE] revealed he had severely impaired cognition.
He required supervision for eating, moderate assistance for transfers, toileting hygiene and maximum
assistance for bed mobility.
Review of the plan of care revealed a smoking care plan which included interventions to instruct about
smoking risks and hazards and to observe clothing and skins for signs of cigarette burns.
Record review revealed the last documented smoking assessment for Resident #20 prior to the survey was
05/30/24.
Observation on 04/29/25 at 1:06 P.M., was made from inside the activity/dining area of the outside smoking
area. Resident #20 was seated in his wheelchair, smoking along with seven other residents and two activity
aids. Resident #20 had his cigarette in his left hand, and was observed using his right hand to brush off
fallen ashes from his sweat pants. A staff member was observed directly in front of him talking to other staff
and residents. After a second observation of the ash dropping, the Activity Manager (AM) #296, who was
also present was notified of the observation. Both the surveyor and the AM #296 went outside. AM #296
grabbed a smoking apron and placed it on Resident #20.
Interview on 04/29/25 at 1:10 P.M., directly following the smoking observation, with AM #29 verified ash had
fallen onto the sweat pants of Resident #20 and she acknowledged he was not always paying attention to
the length of the ash, allowing it to fall onto his clothing. AM #29 further shared she believed he needed an
apron, but he was not care planned to have one. AM #29 admitted she had not brought her concerns to
anyone's attention.
Interview on 05/01/25 at 10:44 A.M., with the Director of Nursing revealed it was her expectation of staff
had a safety concern regarding smoking they would bring it to her attention.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 26 of 61
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
05/01/2025
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Review of the policy titled, Resident Smoking and Procedure, dated 2025 documented each resident
should be individually assessed to determine whether he can safely smoke without supervision and assess
whether he needed an apron. Reassessments should be conducted as necessary.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 27 of 61
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
05/01/2025
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)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, and policy review, the facility failed to ensure
incontinence care was provided correctly. This affected one (#7) of one resident reviewed for incontinence
care. The census was 65.
Findings included:
Medical record review for Resident #7 revealed an admission date of 12/30/22. His medical diagnoses
included arteriosclerotic heart disease, Schizophrenia, Alzheimer's, diabetes, chronic kidney disease, and
convulsions.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was
severely cognitively impaired. His functional status was setup or clean-up assistance for eating,
substantial/maximal assistance for toileting, supervision or touching assistance for bed mobility and
transfers. He was always incontinent for bladder and codes for a colostomy. He was coded for wandering.
Review of the care plan dated 03/16/25 for Resident #7 revealed the resident required staff intervention to
complete self-care. Interventions were to assist with toileting needs/incontinence care on routine rounds
and as needed when soiled and at resident's request. Assist as needed with wearing/changing
incontinence undergarments and toileting hygiene. Check and change on routine rounds and as needed.
Observation on 04/28/25 at 2:00 P.M., of incontinence care for Resident #7, revealed Certified Nursing Aide
(CNA) #230 had the resident stand at the bedside, pulled his pants down, removed the incontinence
product that was moderately wet. CNA #230 then proceeded with a wet washcloths without soap (the soap
was observed sitting on the bedside table), took the unsoaped wet wash cloths and wiped from back to
front on right side and then back to front on the left side and barely touching the penis to clean. Then
placed a new dry incontinence product.
Interview on 04/28/25 at 2:15 P.M., with the CNA #230 confirmed the resident was moderately wet, she
didn't use soap for the washcloths and she didn't wipe the penis in a thorough manner.
Review of the policy titled, Perineal Care dated 10/01/10 revealed: For a male resident:
a. Wet washcloth and apply soap or skin cleansing agent.
b. Wash perineal area starting with urethra and working outward. (Note: If the resident has an indwelling
catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently
rinse and dry the area.)
(1) Retract foreskin of the uncircumcised male.
(2) Wash and rinse urethral area using a circular motion.
(3) Continue to wash the perineal area including the penis, scrotum and inner thighs. Do not reuse
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 28 of 61
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
05/01/2025
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)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the same washcloth or water to clean the urethra. Thoroughly rinse perinea! area in same order, using fresh
water and clean washcloth. (Note: If the resident has an indwelling catheter, hold the tubing to one side and
support the tubing against the leg to avoid traction or unnecessary movement of the catheter.) Gently dry
perineum following same sequence. Reposition foreskin of uncircumcised male. Instruct or assist the
resident to turn on his side with his upper leg slightly bent, if able. Rinse washcloth and apply soap or skin
cleansing agent. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus,
and the buttocks. Dry area thoroughly.
This deficiency represents the noncompliance investigated under Complaint Numbers OH00164520 and
OH00164238.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 29 of 61
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
05/01/2025
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)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the medical record, staff interviews, and policy review, the facility failed to adequately monitor and
implement interventions timely for residents with significant weight loss. This affected three (#18, #26, and
#53) residents of eight reviewed for nutrition. The facility census was 65.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #53 revealed an admission date of 08/13/24. Diagnoses
included dementia, emphysema, and major depressive disorder.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was
not able to complete a Brief Interview for Mental Status (BIMS) because she was rarely/never understood.
This resident was assessed to require setup with eating, supervision with toileting, dressing, and transfers,
and independent with bathing.
Review of the care plan dated 02/04/25 revealed Resident #53 had a nutritional problem related to
mechanical altered texture and consistency and underweight. Interventions included administer
medications as ordered, provide and serve diet as ordered, provide nectar thick liquids as ordered, and
registered dietician to evaluate and make diet change recommendations as needed.
Review of the progress note dated 02/04/25 at 5:35 P.M., revealed Resident #53 had a significant weight
loss of 6.9 percent (%) in the last 30 days and 8.2% in the last 90 days. Weight loss etiology unknown as no
change in oral intake. House supplement 120 milliliters (ml) and weekly weights for four weeks.
Review of the physician order dated 03/04/25 revealed Resident #53 was ordered a house supplement two
times a day for supplement - nectar consistency.
Review of the weights for Resident #53 revealed the following: on 11/05/24: 100 pounds (lbs.), on 12/10/24:
96.8 lbs., on
01/15/25: 98.6 lbs., on
02/01/25: 91.8 lbs., on
03/07/25: 94.2 lbs., on
03/24/25: 94 lbs., and on 04/01/25: 92.4 lbs. There was no evidence of weekly weights being completed.
Interview on 04/30/25 at 1:28 P.M., with Dietary Tech (DT) #506 verified weekly weights were not completed
after being recommended for a significant weight loss in February. DT #506 also verified house supplement
was not ordered until 03/04/25.
2. Review of the medical record for Resident #26 revealed an admission date of 08/26/24. Diagnoses
included major depressive disorder, schizoaffective disorder, and generalized anxiety disorder (GAD).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 30 of 61
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
05/01/2025
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)
F 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had
severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. This
resident was assessed to require setup with eating, partial assistance with toileting, bathing, supervision
with dressing and transfers.
Review of the care plan dated 04/08/25 revealed Resident #26 had a nutritional problem related to major
depression, psychoactive medications, history of refusal of follow up weights. Interventions included
administer medications as ordered, providing and served diet as ordered, providing and served
supplements as ordered, and registered dietician to evaluate and make diet change recommendations as
needed.
Review of the progress note dated 09/17/24 at 7:46 P.M. revealed Resident #26 had a significant weight
loss for 30 and 90 days. House supplement 237 milliliters (ml) twice a day and weekly weights for four
weeks for increased monitoring.
Review of the physician order dated 09/17/24 revealed Resident #26 was ordered a house supplement two
times a day for 237 milliliters (ml) by mouth.
Review of the physician order dated 09/18/24 revealed Resident #26 was ordered weekly weights for four
weeks every Thursday.
Review of the physician order dated 10/11/24 revealed Resident #26 was ordered Remeron 7.5 milligrams
(mg), give one tablet by mouth at bedtime for appetite stimulant.
Review of the physician order dated 04/28/25 revealed Resident #26 was ordered house supplement every
shift for supplement 237 milliliters (ml) by mouth.
Review of the weights for Resident #26 revealed the following: on 08/29/24: 144 lbs., on 09/17/24: 128.4
lbs., on 11/05/24: 130.2 lbs., on 12/10/24: 126.3 lbs., on 01/15/25: 128.2 lbs., on 02/01/25: 130.4 lbs., on
03/07/25: 127.4 lbs., and on 04/01/25: 127.3 lbs. There was no evidence of weekly weights being
completed.
Interview on 04/30/25 at 1:37 P.M., with Dietary Tech (DT) #506 verified weekly weights were not completed
as ordered.
3. Review of Resident #18's medical record revealed an admission date of 05/07/24. Diagnoses include
anemia, hypertension, hyperlipidemia, Alzheimer's, dementia, and depression.
Review of the MDS assessment dated [DATE] revealed Resident #18 is cognitively impaired.
Review of Resident #18's weight on 05/09/24 220 lbs.
Review of Resident #18's care plan, initiated 05/14/24, revealed the resident was at risk for potential
nutritional problems. Interventions included for the Registered Dietician to evaluate and make diet changes,
Occupational Therapist to screen and provide adaptive equipment as needed, and to
monitor/document/report to the physician signs and symptoms of malnutrition.
Review of resident #18's nutritional assessment dated [DATE] revealed Resident #18 is on a regular diet
with thin liquids. Resident #18 is able to feed themselves with no issues noted.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 31 of 61
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
05/01/2025
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)
F 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident #18's weight log revealed the following weights: on 05/14/24: 224 pounds (lbs)., on
05/21/24: 223 lbs., on 05/29/24: 221.5 lbs., on 06/04/24: 221.3 lbs., on 07/16/24: 213.5 lbs., on 08/26/24:
207 lbs., on 09/09/24: 205 lbs., on 10/04/24: 199.8 lbs., and on 10/08/24: 201.5 lbs
Review of Resident #18's progress note date 10/08/24 revealed that Resident #18 was triggered for
significant weight loss of 10% over six months. Further review of the progress note revealed that resident
#18 was consuming 75-100% of meals and a house nutritional supplement of 237 milliliters (ml) once a day
was ordered.
Review of Resident #18's weight log revealed that no weights were taken in the month of November.
Review of Resident #18's weight on 12/10/24 was 189 lbs.
Review of Resident #18's progress note dated 12/10/24 revealed that Resident #18 was triggered again for
significant weight loss of 6.34% from 10/08/24 to 12/10/24. Further review of the progress note revealed a
reweigh was order.
Review of Resident #18's weight on 12/17/24 was 189.8 lbs.
Review of Resident 18's progress note dated 12/20/24 revealed that Resident #18 reweigh on 12/17/24
confirms weight loss. Further review revealed that Resident #18 was accepting of his diet and no new
recommendations were given.
Review of Resident #18's weight on 01/10/25 was 185.4 lbs.
Review of Resident #18's progress note dated 01/10/25 revealed that he was triggered for significant
weight loss of 8% in 90 days and 13.2% in 180 days. Further review revealed that Resident #18 was
accepting his diet and weekly weights were ordered.
Review of Resident #18's weight log revealed: on 01/15/25: 185.4 lbs. and on 02/01/25: 179.6 lbs.
Review of Resident #18's nutritional assessment dated [DATE] revealed an recommendation to initiate
weekly weights and increase the house nutritional supplement to 237 ml twice a day.
Review of Resident #18's weight log revealed on 03/10/25: 181.6 lbs. and on 03/24/25: 178.8 lbs.
Review of Resident #18's progress note dated 03/25/25 revealed Resident #18 had a weight loss of 26.2
pounds in 180 days which was a loss of 12.8%. Further review revealed a recommendation that the
physician should be notified.
Review of Resident #18's weight on 04/01/25 was 174.6 lbs.
Review of Resident #18's progress note dated 04/08/25 revealed Resident #18 had a weight loss of 25.2
pounds in 180 days which was a loss of 12.6%. Further review revealed a recommendation the physician
should be notified.
Interview on 04/30/25 at 3:54 P.M.,with Registered Dietician (RD) #504 revealed the nutritional
assessments were completed by diet technicians, however she reviewed the residents record in October
and added the first house nutritional supplement. RD #504 confirmed that Resident #18 was still under
excessive weight loss review. RD #504 revealed Resident #18's Body Mass Index (BMI) was within
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 32 of 61
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
05/01/2025
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)
F 0692
normal limits and therefore his nutritional needs were met.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 04/30/25 at 6:49 P.M., with Regional Nurse #508 revealed Resident #18's weight loss was
desired, but confirmed that no documentation of a weight loss plan was recorded. Regional Nurse #508
confirmed that Resident #18 continued to lose weight with interventions in place and the weekly weights
were not documented when ordered. Regional Nurse #508 revealed the plan is to maintain Resident #18
around 170 lbs.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 33 of 61
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
05/01/2025
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical
record review for Resident #1 revealed an admission date of 09/06/18. His medical diagnoses included
atrial fibrillation, cancer, coronary artery disease, heart failure, and peripheral vascular disease.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was
cognitively intact.
Review of the current physician orders and times of medication administration dated 04/27/25 for Resident
#1 revealed Coreg 12.5 milligrams (mg) to give one twice a day was scheduled at 4:00 P.M. and given at
6:55 P.M. Hydralazine 50 mg to give one three times a day was scheduled for 8:00 P.M. and was given at
12:41 A.M.
Interview with Resident #1 on 04/28/25 at 10:11 A.M. revealed the agency nurse's were awful and his
medications weren't on time. He reported there are times when he gets him morning medications in the
evening, but didn't know a date or time.
5. Medical record review for Resident #7 revealed an admission date of 12/30/22. His medical diagnoses
included arteriosclerotic heart disease, Schizophrenia, Alzheimer's, diabetes, chronic kidney disease, and
convulsions.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was
severely cognitively impaired. His functional status was setup or clean-up assistance for eating,
substantial/maximal assistance for toileting, supervision or touching assistance for bed mobility and
transfers. He was always incontinent for bladder and codes for a colostomy. He was coded for wandering.
Review of the current physician orders and times of medication administration dated 05/01/25 for Resident
#7 revealed Depakote 250 mg to give one twice a day, Ranexa 1000 mg, to give one twice a day,
Famotidine 20 mg. to give one twice a day, Levetiracetam 500 mg. to give one twice a day for convulsions,
Sucralfate one gram to give one three times a day were all scheduled at 8:00 A.M. and given at 11:07 A.M.
6. Medical record review for Resident #367 revealed an admission date of 03/11/25. Her medical diagnoses
included chronic pulmonary obstruction, depression, hyperlipidemia, anxiety, atrial fibrillation, diabetes, and
hypertension.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #367 was
cognitively intact.
Review of the current physician orders and times of medication administration dated 04/27/25 for Resident
#367 revealed Theophylline Extended Release (ER) to give 300 mg twice a day, Lactulose to give 30
milliliters (ml) twice a day, Apixaban 5 mg to give one twice a day, Ativan to give one mg twice a day,
Budesonide-Formoterol Fumarate Inhalation Aerosol to give two puffs twice a day, Albuterol one vial to give
four times a day, all scheduled to be given at 8:00 A.M. and given at 10:49 A.M. Further review of the
medications revealed Theophylline Extended Release (ER) to give 300 mg twice a day, Lactulose to give 30
milliliters (ml) twice a day, Apixaban 5 mg to give one twice a day, Ativan
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 34 of 61
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
05/01/2025
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
to give one mg twice a day, Budesonide-Formoterol Fumarate Inhalation Aerosol to give two puffs twice a
day, Albuterol one vial to give four times a day were scheduled for 8:00 P.M. and not given till 12:26 A.M.
Interview with Resident #367 on 04/28/25 at 3:16 P.M. revealed her medications were given late.
7. Medical record review for Resident #368 [NAME] revealed an admission date of 04/23/25. Medical
diagnoses included hypertension, hyperlipidemia, and depression.
Review of the admission progress note dated 04/23/25 revealed Resident #368 was cognitively intact.
Functional status was unsteady gait and balance was poor.
Review of the current physician orders and times of medication administration dated 04/27/25 for Resident
#368 revealed to give Ranolazine ER 500 mg one twice a day, Budesonide-Formoterol Fumarate Inhalation
Aerosol to give two puffs twice a day, Spiriva Respimat Inhalation 2.5 micrograms (mcg) to give two
inhalation two times a day, Risperdal 4 mg to give one twice a day, Carvedilol 12.5 mg, Metformin 1000 to
give twice a day, Doxycycline 100 mg to give one two times a day, Carafate 1 gram to give one four times a
day were all scheduled for 8:00 A.M. and given at 9:32 A.M. Further review revealed Lantus to give 40 units
at bedtime, Famotidine 20 mg to give one at bedtime, Budesonide-Formoterol Fumarate Inhalation Aerosol
to give two puffs twice a day, Risperdal 4 mg to give one twice a day, Ranolazine ER 500 mg to give twice a
day, Spiriva Respimat Inhalation 2.5 micrograms (mcg) to give two inhalation two times a day, Trazadone
300 mg to give one at bedtime, and Vistaril 50 mg to give one capsule three times a day. All these
medications were scheduled at 8:00 P.M. and given at 12:43 A.M.
Interview with Resident #206 on 04/28/25 at 10:05 A.M. revealed his medications were messed up and late.
Interview with the Licensed Practical Nurse (LPN) #206 on 05/01/25 at 7:12 A.M., revealed she was the
nurse who worked the night shift on 04/27/25 and verified she was late with the medications. LPN #206
stated it was due to having 35 residents and dealing with behaviors on her assignment. LPN #206 reported
it was better to be late then to not give them at all. She reported there was enough staff.
Interview with the LPN #281 on 05/01/25 at 8:03 A.M., revealed she worked dayshift on 04/27/25. LPN
#281 confirmed she was late with her medications because a resident had to go out to the hospital for
seeping of his legs and she got behind. LPN #281 reported there were other nursing staff working, but she
didn't ask them to help her get caught up because they were busy too.
Review of the policy titled Medication Administration dated 2001 revealed medications are administered
within one (l} hour of their prescribed time, unless otherwise specified (for example, before and after meal
orders).
This deficiency represents the noncompliance investigated under Complaint Number OH00164520.
Based on record review, staff and resident interviews, review of Medscape resource website and policy
review, the facility failed to ensure extended release medications were not crushed, administer medications
as ordered and/or in a timely manner. This affected six (#1, #7, #26, #266, #366, and #367 ) of 11 residents
reviewed for medication administration. The facility census was 65.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 35 of 61
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
05/01/2025
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)
F 0755
Findings included:
Level of Harm - Minimal harm
or potential for actual harm
1. Review of medical record for Resident #366 revealed admission date of 02/19/25. The resident was
admitted with diagnoses including cellulitis, morbid obesity, type two diabetes mellitus, unstageable
pressure ulcer of right heel.
Residents Affected - Some
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief
Interview Mental Status (BIMS) score of 13 indicating intact cognition. She required set up for eating, was
dependent with toileting hygiene, maximum assistance for showers, transfers and moderate assistance for
bed mobility.
Review of the physician orders revealed an order for Coreg (hypertension) 6.25 milligrams (mg) twice daily,
Torsemide (Congestive heart failure) 40 mg twice daily with a start date of 02/19/25, Allopurinol (gout) 100
mg (mg) daily, Buspirone (depression) 10 mg daily, Protonix (reflux) 40 mg daily, and Paxil (depression) 40
mg daily with a start date of 02/20/25.
Record review of the February Medication Administration Record (MAR) revealed Coreg was scheduled for
8:00 A.M. and 8:00 P.M., with no documentation it had been administered on 02/20/25 or at 8:00 A.M. on
02/21/25, 02/22/25, or 02/23/25; Torsemide was scheduled for 8:00 A.M. and 8:00 P.M., with no
documentation it had been administered on 02/20/25 or at 8:00 A.M. on 02/21/25, 02/22/25, or 02/23/25 at
8:00 A.M. or 8:00 P.M.; Allopurinol, Buspirone and Paxil were scheduled for 8:00 A.M., with no
documentation they were administered as prescribed on 02/20/25, 02/21/25, 02/22/25 or 02/23/25; and
Protonix was scheduled at 6:00 A.M., with no documentation it had been administered as prescribed on
02/21/25, 02/22/25 or 02/23/25.
Interview on 05/01/25 at 11:22 A.M., with the Director of Nursing verified there was no documentation
medications for Resident #366 had been administered as prescribed on 02/20/25 through 02/23/25.
2. Review of medical record for Resident #266 revealed admission date of 06/24/24, with diagnoses
including major depression disorder recurrent with severe psychotic symptoms, dementia and anxiety.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed he had severely impaired
cognition required set up assistance for eating and supervision for bed mobility, transfers and toileting
hygiene.
Observation of medication administration on 04/29/25 at 7:58 A.M., with Licensed Practical Nurse (LPN)
#293, for Resident #266, revealed he administered Vascepa (statin) one gram (gm) two tablets, Ciprofloxin
(antibiotic) 250 milligrams (mg), Eliquis (anticoagulant) 2.5 mg, Lasix (diuretic) 20 mg, Gabapentin
(neuropathy) 800 mg, Senna-Plus (laxative) 8.6 mg/50 mg, Refresh Eye Drops (eye lubricant) one drop for
each eye, and Namenda (Dementia) 10 mg.
Review of the physician orders revealed a physician order for Namenda five mg daily with a start date of
03/17/25.
Interview on 04/29/25 at 8:42 A.M. , with LPN #293 verified he had given 10 mg of Namenda to Resident
#266 in error.
3. Review of medical record for Resident #26 revealed admission date of 06/24/24 with diagnoses including
major depression disorder recurrent with severe psychotic symptoms, dementia and anxiety.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 36 of 61
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
05/01/2025
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed had severely impaired cognition
required set up assistance for eating and supervision bed mobility, transfers and moderate assistance for
toileting hygiene.
Observation on 04/29/25 at 7:48 A.M., with Licensed Practical Nurse (LPN) #293 was observed to crush
Plavix (anticoagulant) 75 milligrams (mg) and Wellbutrin Extended Release 150 mg and added it to a
medicine cup containing pudding. He then opened a capsule of Auvelity (depression) 45 mg/105 mg, added
it to the pudding and mixed it together prior to administering it to Resident #293.
Interview on 04/29/25 at 8:42 A.M. , with LPN #293 verified he crushed the medications.
Review of Medscape website at
https://reference.medscape.com/drug/wellbutrin-aplenzin-bupropion-342954#91 revealed, Swallow the
tablets whole. Do not crush or chew the tablets. Doing so can release all of the drug at once, increasing the
risk of side effects.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 37 of 61
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
05/01/2025
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)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, medical record review, staff interview, review of the undated manufacture guidelines, and
review of Medscape resource website, the facility failed to ensure the medication error rate did not exceed
five percent when three medication errors were observed of 25 opportunities resulting in an error rate of 12
percent. This affected three (#26, #266, and #368) of four residents observed for medication administration.
The facility census was 65.
Residents Affected - Few
Findings include:
1. Review of medical record for Resident #266 revealed admission date of 06/24/24, with diagnoses
including major depression disorder recurrent with severe psychotic symptoms, dementia and anxiety.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed he had severely impaired
cognition required set up assistance for eating and supervision for bed mobility, transfers and toileting
hygiene.
Observation of medication administration on 04/29/25 at 7:58 A.M., with Licensed Practical Nurse (LPN)
#293, for Resident #266, revealed he administered Vascepa (statin) one gram (gm) two tablets, Ciprofloxin
(antibiotic) 250 milligrams (mg), Eliquis (anticoagulant) 2.5 mg, Lasix (diuretic) 20 mg, Gabapentin
(neuropathy) 800 mg, Senna-Plus (laxative) 8.6 mg/50 mg, Refresh Eye Drops (eye lubricant) one drop for
each eye, and Namenda (Dementia) 10 mg.
Review of the physician orders revealed a physician order for Namenda five mg daily with a start date of
03/17/25.
Interview on 04/29/25 at 8:42 A.M. , with LPN #293 verified he had given 10 mg of Namenda to Resident
#266 in error.
2. Review of medical record for Resident #26 revealed admission date of 06/24/24 with diagnoses including
major depression disorder recurrent with severe psychotic symptoms, dementia and anxiety.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed had severely impaired cognition
required set up assistance for eating and supervision bed mobility, transfers and moderate assistance for
toileting hygiene.
Observation on 04/29/25 at 7:48 A.M., with Licensed Practical Nurse (LPN) #293 was observed to crush
Plavix (anticoagulant) 75 milligrams (mg) and Wellbutrin Extended Release 150 mg and added it to a
medicine cup containing pudding. He then opened a capsule of Auvelity (depression) 45 mg/105 mg, added
it to the pudding and mixed it together prior to administering it to Resident #293.
Interview on 04/29/25 at 8:42 A.M. , with LPN #293 verified he crushed the medications.
Review of Medscape website at
https://reference.medscape.com/drug/wellbutrin-aplenzin-bupropion-342954#91 revealed, Swallow the
tablets whole. Do not crush or chew the tablets. Doing so can release all of the drug at once, increasing the
risk of side effects.
3. Review of medical record for Resident #368 revealed admission date of 04/29/25 with diagnoses
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 38 of 61
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
05/01/2025
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)
F 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
including fracture of unspecified part of left femur, methicillin resistant staphylococcus aureus and type two
Diabetes Mellitus. The resident remained in the facility.
Observation on 05/01/25 at 9:08 A.M., of Registered Nurse (RN) #240 of medication observation for
Resident #368 revealed her blood glucose was 348 which required eight units of insulin. RN #240 was
observed to clean the hub of the Lispro insulin pen before applying the needle. She then went to the
bedside of Resident #368 and dialed the pen to the number eight. RN #240 then prepared the abdomen of
Resident #368 by cleaning an area with an alcohol swab and proceeded to inject the medication.
Interview on 05/01/25 at 9:12 A.M., directly following the observation, RN #240 verified she did not prime
the needle prior in preparation to administering the required eight units.
Review of the undated manufacture guidelines for Lispro documented the pen must be primed to a stream
of insulin before each injection to make sure the pen is ready to dose. If the pen is not primed too little or
too much insulin may be given.
This deficiency represents the noncompliance investigated under Complaint Number OH00164520.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 39 of 61
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
05/01/2025
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)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record review, review of physician orders, staff interview, and review of manufacture
guidelines, the facility failed to ensure residents were free from significant medication errors. This affected
two (#366 and #368) of five residents reviewed for medications. The facility census was 65.
Residents Affected - Few
Findings include:
1. Review of medical record for Resident #366 revealed admission date of 02/19/25. The resident was
admitted with diagnoses including cellulitis, morbid obesity, type two diabetes mellitus, unstageable
pressure ulcer of right heel.
Review of the admission Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental
Status (BIMS) score of 13 indicating intact cognition. She required set up for eating, was dependent with
toileting hygiene, maximum assistance for showers, transfers and moderate assistance for bed mobility.
Review of the physician orders revealed an order for Lispro (fast acting insulin) 100 units per (/) milliliter (ml)
sliding scale before meals and at bedtime. If blood glucose 150 to 200 give three units, if 201 to 250 give
six units, if 251 to 300 give nine units, if 301-350 give 12 units, if 351-400 give 12 units, if 401-450 give 18
units, if over 450 call physician with a start date of 02/19/25.
Review of the February Medication Administration Record (MAR) revealed blood glucose was scheduled to
be obtained at 7:00 A.M., 11:00 A.M., 4:00 P.M. and 8:00 P.M. Further review revealed no documentation
blood glucose was checked at all on 02/20/25, and was only documented at 8:00 P.M. on 02/21/25,
02/22/25 and 02/23/25.
Interview on 05/01/25 at 11:22 A.M. with the Director of Nursing verified there was no documentation
glucose monitoring for Resident #366 had been obtained as ordered on 02/20/25 through 02/23/25, and no
insulin coverage was provided if needed.
2. Review of medical record for Resident #368 revealed admission date of 04/29/25 with diagnoses
including fracture of unspecified part of left femur, methicillin resistant staphylococcus aureus and type two
Diabetes Mellitus.
Observation on 05/01/25 at 9:08 A.M., of Registered Nurse (RN) #240 of medication observation for
Resident #368 revealed her blood glucose was 348 which required eight units of insulin. RN #240 was
observed to clean the hub of the Lispro insulin pen before applying the needle. She then went to the
bedside of Resident #368 and dialed the pen to the number eight. RN #240 then prepared the abdomen of
Resident #368 by cleaning an area with an alcohol swab and proceeded to inject the medication.
Interview on 05/01/25 at 9:12 A.M., directly following the observation, RN #240 verified she did not prime
the needle prior in preparation to administering the required eight units.
Review of the undated manufacture guidelines for Lispro documented the pen must be primed to a stream
of insulin before each injection to make sure the pen is ready to dose. If the pen is not primed too little or
too much insulin may be given.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 40 of 61
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
05/01/2025
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)
F 0760
This deficiency represents the noncompliance investigated under Complaint Number OH00164520.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 41 of 61
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
05/01/2025
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview and policy review, the facility failed ensure medications
were not left unattended in residents rooms and safely store medications. This affected three residents (#7,
#9 and #41) directly and had the potential to affect the 16 residents who resided on Unit #2. The facility
census was 65.
Findings included:
1. Medical record review for Resident #7 revealed an admission date of 12/30/22. His medical diagnoses
included arteriosclerotic heart disease, Schizophrenia, Alzheimer's, diabetes, chronic kidney disease, and
convulsions.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was severely
cognitively impaired. His functional status was setup or clean-up assistance for eating, substantial/maximal
assistance for toileting, supervision or touching assistance for bed mobility and transfers. He was always
incontinent for bladder and codes for a colostomy. He was coded for wandering.
Observation on 04/28/25 at 2:59 P.M., revealed Licensed Practical Nurse (LPN) #293 on 04/28/25 at 2:59
P.M. revealed LPN #293 was seen in Resident #7's room with a medicine cup of what looked like vanilla
pudding. He walked out of the room with the medicine cup and walked down the hall to his medication cart
and threw the cup in the trash.
Interview and observation with the LPN #293 on 04/28/25 at 3:00 P.M., revealed the LPN #293 took the
medication cup out of the trash and it looked like vanilla pudding with different colored specks in the
pudding. LPN #293 said the cup was pudding with what looked like crushed medications left over from the
night before and he was discarding it in the trash. He confirmed the medications were left at the bedside
and should not be.
Interview with Registered Nurse (RN) #512 on 05/01/25 at 8:07 A.M. revealed he worked at the facility
several month ago and took care of Resident #7. RN #7 reported he had left a cup of medications in the
room and the family came into the facility had a problem with him leaving the meds in the room. RN #512
reported he thought the resident would be able to take the medications if he left the room, but said this
wasn't the policy and procedure for this. The nurses were supposed to watch the residents take there
medications.
2. Review of the medical record for Resident #9 revealed an admission date of 03/08/25. Diagnoses
included abdominal pain, spinal stenosis, gastritis and malnutrition.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had moderate
cognitive impairment with a Brief Interview Mental Status (BIMS) of 9.
Review of active monthly physician orders for April 2025 revealed orders for 8:00 A.M, to include:
Aripiprazole oral tab 5 milligram mg, vision plus oral capsule to give one capsule, Paxil oral tab 10 mg once
daily to be given along with 20 mg tab and 10 mg tablet for 30 mg total, Neurontin Oral Capsule 100 mg,
Metoprolol Tartrate oral tab 50 mg, Naloxegol Oxalate oral tab 25 mg, Pantoprazole
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 42 of 61
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
05/01/2025
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Sodium oral tab 40 mg once daily, Sennosides oral tab 8.6 mg to give two tablets once daily, Eliquis oral tab
5 mg, Torsemide oral tab 20 mg, Famotidine oral tab 20 mg, and Levothyroxine Sodium tab 125 micrograms
once daily.
Review of the Medication Administration Record (MAR) dated 04/28/25 revealed 13 orders/pills were
signed off as given during the morning shift medication pass.
Observation on 04/28/25 at 10:08 A.M., revealed a cup of medications were seen to be left on the bedside
table with staff out of sight of resident and the medications.
Interview and observation on 04/28/25 at 10:09 A.M., with Registered Nurse (RN) #513 confirmed a cup of
pills was left at the bedside. RN #513 confirmed the pill contained eight pills with seven different
medications. At first RN #513 stated the night shift staff left that cup at bedside and then stated resident
wasn't feeing well and gotten sick so the aide was cleaning her up and that was the reason she left the pills
in the resident's room
Interview on 04/28/25 at 11:00 A.M., with RN #513 confirmed she documented in the MAR that resident
had been administered all morning medications (13 pills). RN #513 revealed she was passing pills when
resident got sick and had to stop and resume at a later time. RN #513 was unable to identify what
medications were in the cup and left out in Resident's room.
Interview on 04/28/25 at 3:00 P.M., with Resident #9 confirmed staff regularly leave medications at bedside
and leave the room while leaving the pills.
3. Observation on 04/28/25 at 9:39 A.M., revealed Resident #41 appeared asleep in his bed. The bedside
table was beside the bed and a medicine cup containing multiple pills was observed.
Interview at the time of the observation, with Licensed Practical Nurse (LPN) #304 revealed she had not
given any pills to Resident #41 this day. LPN #304 stated she had entered the room, but he was not awake
and she was going to return later to give his morning pills. LPN #304 verified there were pills in the
medicine cup on his bedside table. LPN #304 removed the medicine cup from the bedside table. She
counted the pills and stated there were 12 pills and one capsule which she removed from the room and
discarded.
Interview on 04/30/25 at 4:00 P.M., with Clinical Regional Licensed Practical Nurse (CRLPN) #500 revealed
Resident #41 did not have an order for self-medication administration.
Review of the undated facility policy, Administering Medications residents may self-administer medication
only if the attending physician in conjunction with the interdisciplinary care team, has determined they have
the decision-making capacity to do so safely.
4. Observation on 04/29/25 at 9:07 A.M., with LPN #304 of the medication cart revealed there was one
loose red pill and one loose white pill in the top drawer. There was one loose vial of Budesonide (inhalation
medication for asthma) vial in the bottom of the medication drawer. There were no boxes for Budesonide of
the medication in the drawer.
Interview on 04/29/25 at 9:07 A.M., with LPN #304 verified there were two loose pills in the top drawer of
the medication cart and one vial of Budesonide in the bottom drawer. She acknowledged the medication
should be stored outside of the original container and discarded the medication.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 43 of 61
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
05/01/2025
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Review of the policy, Medication Labeling and Storage revised February 2023 documented Medications
and biologics are stored in the packaging, containers or dispensing systems which they are received.
Medications are to be stored in an orderly manner.
This deficiency represents non-compliance investigated under Complaint Number OH00164238.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 44 of 61
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
05/01/2025
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)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, staff and resident interviews, medical record record review, meals substitute log review, menu
review, diet tech audit review, and policy review, the facility failed to follow meal tickets and scheduled menu
and an updated/ accurate substitution log. This affected two (#16 and #30) of three residents reviewed for
nutrition with potential to affect all residents who receive meals from the dining room. Facility identified all
facility residents eat food from the kitchen. The facility census was 65.
Findings include:
1. Review of the medical record for Resident #30 revealed an admission date of 08/13/24. Diagnoses
included pneumonia, malnutrition, hemiplegia, heart failure, vascular disease, and respiratory failure.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had moderate
cognitive impairment with a Brief Interview Mental Status (BIMS) of 11.
Interview and observation on 04/28/25 at 12:34 P.M. with Resident #30 revealed the food that was served
did not match the meal ticket. Resident #30's food ticket was dated 04/27/24, Sunday lunch and stated
resident had a mechanical diet. It also stated resident should receive broccoli and potato soup, basked ziti
with four cheese, shredded lettuce, and applesauce. Resident #7 only had a cup of vegetable soup and a
small ice cream cup on her tray. Resident #30 reported what she gets served never matches the ticket or
the menu. Resident #30 stated she was still hungry and would like more to eat than just a cup of soup.
Interview and observation on 04/28/25 at 12:35 P.M., with Certified Nurse Aide #282 confirmed residents
tray items did not match the ticket and confirmed the kitchen did not typically follow the posted menu and
they heard regular complaints from residents about the items not matching the tickets on the tray.
2. Review of Resident #16's medical record revealed an admissions date of 02/07/25. Diagnoses include
coronary artery disease, hypertension, diabetes mellitus, seizures, anxiety, and depression.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 is cognitively
intact.
Interview with Resident #16 on 04/28/25 at 3:09 P.M., revealed she does not receive a menu for each meal.
Resident #16 stated that she doesn't know what she will be getting for each meal.
Observation of the lunch served on 04/28/25 at approximately 12:30 P.M., revealed that chicken salad
sandwiches were being served instead of the meat loaf that was listed on the scheduled menu for the day.
Interview dated 04/29/25 at 12:53 P.M., with Kitchen Manager (KM) #237 confirmed the resident meals do
not always match what was on the menu. KM #237 revealed the facility was unable to find the complete
substitution log.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 45 of 61
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
05/01/2025
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)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Review of substitution log dated April 2025 revealed the 04/28/25 change in the lunch meal was not
included on the substitution log. It mentioned dinner meal it added chicken salad in place of salad but
included no mention of switching the meat loaf and the mashed potatoes and gravy and the fruit cup.
Observation and interview on 04/29/25 at 3:10 P.M., with Diet Tech #506 revealed she typically would do a
test tray and audits about monthly and revealed in recent audits she completed found facility did not follow
the menu or spreadsheets. She also revealed when she had requested the substitution logs for the last two
months, facility was unable to supply any evidence of the substitution log.
Review of facility diet tech audit dated 03/25/25 revealed standard recipes (including puree recipe) was not
being followed, and substitution log was not found.
Review of facility diet tech audit dated 04/29/25 revealed nutrition recommendations were not addressed
from the previous visit. Menu with spreadsheets were not followed, and substitution log was not found.
Review of the menu for 04/28/25 revealed the lunch meal included homemade meatloaf, mashed potatoes
and gravy, bread, peas and carrots, and mixed fruit.
Review of facility policy titled, Menus, dated 04/25/24 revealed menus should be prepared in advance.
Menus should be approved by the dietician if the meal changes for any reason from the planned menu, the
reason for the change should be documented and maintained in the kitchen.
This deficiency represents the noncompliance investigated under Complaint Number OH00164520.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 46 of 61
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
05/01/2025
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)
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an
observation, staff and resident interviews, medical record review, diet tech audit review, and policy review,
the facility failed to ensure food had a palatable taste and was served at an appetizing temperature. This
affected four (#1, #16, #30, and #367) of six residents reviewed for dietary needs. The facility identified all
residents eat food from the kitchen. The facility census was 65.
Residents Affected - Many
Findings include:
1. Review of the medical record for Resident #30 revealed an admission date of 08/13/24. Diagnoses
included pneumonia, malnutrition, hemiplegia, heart failure, vascular disease, and respiratory failure.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had moderate
cognitive impairment with a Brief Interview Mental Status (BIMS) of 11.
Interview on 04/29/25 at 4:32 P.M. with Resident #7 revealed food wasn't good and didn't have good taste.
2. Review of the medical record for Resident #367 revealed an admission date of 03/11/25. Diagnoses
included chronic obstructive pulmonary disease, depression, atrial fibrillation, and diabetes.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #367 was cognitively
intact with a Brief Interview Mental Status (BIMS) of 15.
Interview on 04/28/25 at 3:16 P.M., with Resident #367 revealed food was not good and was cold.
3. Review of the medical record for Resident #1 revealed an admission date of 09/06/18. Diagnoses
included atrial fibrillation, diabetes, heart disease and dysphasia.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively
intact with a Brief Interview Mental Status (BIMS) of 15.
Interview on 04/28/25 at 10:25 A.M., with Resident #1 revealed food that was served was not hot.
Review of facility diet tech audit dated 03/25/25 revealed puree food looked pasty, lacked flavor and
appearance, standard recipes (including puree recipe) not being followed.
Review of facility diet tech audit dated 04/29/25 revealed nutrition recommendations were not addressed
from the previous visit. Food was not cooked in a way to conserve nutritive value, flavor and appearance.
Upon diet tech test tray it was determined the food was very salty and unappealing, food was cold and
below an acceptable range.
4. Review of Resident #16's medical record revealed an admissions date of 02/07/25. Diagnoses include
coronary artery disease, hypertension, diabetes mellitus, seizures, anxiety, and depression.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 is cognitively
intact.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 47 of 61
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
05/01/2025
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)
F 0804
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Interview with Resident #16 on 04/28/25 at 3:09 P.M. revealed the food being served does not taste good.
Resident #16 stated that the food is not served warm enough and is often cold.
Observation on 04/29/25 at 11:55 A.M., with Dietary [NAME] #214 revealed prior to the start of tray line, the
cream of rice had a temperature of 140 degrees, the pureed [NAME] chicken had a temperature of 135
degrees, the pureed vegetables had a temperature of 148 degrees and the regular [NAME] chicken had a
temperature of 176 degrees.
Observation on 04/29/25 at 12:41 P.M., with Dietary [NAME] #214 revealed when plating the test tray, the
cream of rice had a temperature of 137 degrees, the pureed vegetables had a temperature of 118 degrees
and the regular [NAME] chicken had a temperature of 155 degrees. When asked about what temperature
staff was looking for the tray line items, Dietary [NAME] #214 revealed 165-175 degrees. The test tray left
the kitchen at 12:47 P.M.
Observation and interview on 04/29/25 at 1:06 P.M., with Kitchen Manager #237 revealed the cream of rice
had a temperature of 94 degrees, the pureed vegetables had a temperature of 91 degrees and the regular
[NAME] chicken had a temperature of 92 degrees. Kitchen Manager #237 along with survey team tried the
items and confirmed they tasted cold and the [NAME] chicken tasted very salty. Kitchen Manager #237 also
revealed the cream of rice tasted bland. Kitchen Manager #237 revealed facility had metal warming dish to
keep plates warm and don't use them but stated we could start using them.
Observation and interview on 04/29/25 at 3:10 P.M., with Diet Tech #506 revealed she typically with do a
test tray and audits about monthly and revealed the last two audits she completed found facility palatability
concerns with taste and temperature. She revealed food should be served over 120 degrees and reported
she also tried the meals this date and found the items to be cold and the meat to be salty. She revealed she
also spoke with residents in the dining room who also confirmed the food was cold and the meat was salty.
Review of the policy titled, Palatability and Nutritive Value, dated 06/27/23 revealed food shall be prepared,
held and served in a manner that preserves nutritive value and palatability. Hot foods would be held at 135
degrees. The facility shall make best efforts to present hot foods hot at point of service by using thermal lids
and bases and thermal pellets as needed. Food service staff shall monitor palatability of food at point of
service by periodic test tray evaluation.
This deficiency represents the noncompliance investigated under Complaint Number OH00164520.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 48 of 61
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
05/01/2025
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)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, staff and resident interviews, recipe review and diet tech audit review, the facility failed to
ensure pureed food was made to the correct consistency and the menu was followed. This affected four
(#27, #46, #54, and #62) of four residents who received purred diets. The facility census was 65.
Findings include:
Observation and interview on 04/29/25 at 11:14 A.M., with Dietary [NAME] #214 revealed she made four
servings of pureed [NAME] chicken. She placed four, four ounce scoops into the blender along with one
and a half cups of chicken gravy followed by an additional cup of gravy for a total of two and a half cups of
gravy. Dietary [NAME] #214 revealed she was looking for a mashed potato consistency. The mixture was
blended and poured into a container without ever scraping the sides. The final mixture was tasted by staff
and surveyors and found several chunks of chicken which Dietary [NAME] #214 acknowledged. The mixture
was returned to the blender and staff continued to blend to a smoother consistency.
Observation on 04/29/25 at 12:08 P.M., revealed Dietary Staff #214 made up a puree dish on the tray line.
The [NAME] chicken was scooped onto the late and spread out due to being overly thinned with gravy.
Interview on 04/29/25 at 1:06 P.M., with Kitchen Manager #237 confirmed puree food should hold a shape
and not spread on the plate.
Interview on 04/29/25 at 3:10 P.M., with Diet Tech #506 revealed puree should be a smooth consistency
without lumps or chunks of any kind and should hold a scoop shape. She revealed she completed test trays
every few weeks and revealed she had brought up concerns related to puree food being chunky and not to
the correct consistency. Diet Tech #506 also revealed staff should be using a recipe with instructions for
how but thinning liquid (i.e. gravy) and how much thickener should be used.
Review of the undated recipe for [NAME] chicken for making puree texture revealed gravy or thinning agent
should be added in measurements of tablespoons. It did not given any instructions for using two and a half
cups of thinning liquid (gravy) for four servings.
Review of diet tech audit dated 03/25/25 revealed puree food looked pasty, lacked flavor and appearance,
standard recipes (including puree recipe) not being followed.
Review of diet tech audit dated 04/29/25 revealed nutrition recommendations were not addressed from the
previous visit. Standard recipes (including puree recipe) not being followed. It was also noted puree food
not made to proper consistency, upon diet tech test tray it was determined the food was very salty and
unappealing, food was cold and below an acceptable range.
This deficiency represents the noncompliance investigated under Complaint Number OH00164520.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 49 of 61
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
05/01/2025
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff interviews and policy review, the facility failed to ensure food was stored in a safe and
sanitary manner. This had the potential to affect all 65 residents. The facility census was 65.
Findings include:
Observation of the walk in freezer on 04/28/25 at 8:49 A.M. revealed frozen waffles in a bag without a date.
Ice was observed on the tops of boxes of Mighty Shakes and B/C Topping that were stored under the
freezer condenser. Interview with the Kitchen Manger (KM) #237 confirmed that the frozen waffles did not
have a date. KM #237 confirmed that the condenser appeared to be leaking and creating a build up of ice
on the boxes stored below.
Observation on 04/28/25 at 8:54 A.M. revealed Dietary Aide (DA) #284 testing the chemical dish machine
with a chlorine test strip that appeared to be a light purple. Interview with DA #284 verified that the test strip
showed that the chlorine concentration in the dish machine was at 25 parts per million (PPM). DA #284
verified that the dish machine should have a concentration of 50-100 PPM of chlorine.
Observation of the refrigerator on 04/28/25 at 8:55 A.M. revealed an open bottle of ketchup dated 04/19/25,
26 containers of thickened cranberry cocktail with an expiration date of 04/18/25, 15 containers of thickened
lemonade with an expiration date of 02/05/25, an open package of slice turkey without a date and a carton
of B/C topping without a date. Interview with DD #237 confirmed that the ketchup, cranberry cocktail,
lemonade were past their expirations date. KM #237 confirmed that the sliced turkey and B/C topping were
not dated.
Observation of the dry stock on 04/28/25 at 9:08 A.M. revealed a container of flour without a date marked, a
container of egg noodles without a date marked, and a box of care thickened hot cocoa mix with an
expiration date of 03/01/25. Interview with KM #237 confirmed that both containers did not have a date
marked and that the cocoa mix was past the expiration date.
Observation in the kitchen on 04/28/25 at 9:14 A.M. revealed an open bag of hot dog buns without a date
marked. Interview with KM #237 confirmed that the hot dog buns did not have a date on the bag.
Observation of the preparation of the pureed lunch menu on 04/29/25 at 11:18 A.M. revealed Dietary
[NAME] (DC) #214 pour the pureed [NAME] chicken into a metal pan that had a yellow residue inside.
Interview DC #214 confirmed that there was a residue in the metal pan and that she believed that it was a
residue from chicken base. DC#214 confirmed that she grabbed the pan from the stack of clean pans that
were stored under the preparation table.
Observation of the dry stock on 04/29/25 at 11:38 A.M. revealed an open bags of spaghetti noodles, navy
beans and white rice without a date marking when they were opened. Interview with KM #237 verified that
the bags were not marked with an opened date.
Observation of the walk in cooler on 04/29/25 at 11:39 A.M. revealed raw hamburger meat being stored
above gallons of milk and bags of cheese. Interview with KM #237 confirmed that the raw meat was stored
above ready to eat food.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 50 of 61
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
05/01/2025
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Further observation of the lunch service on 04/29/25 at 12:10 P.M. revealed KM #237 enter the kitchen with
a metal pot and filled the pot with water at the prep sink. KM #237 then placed several hot dogs into the pot
and placed in on the stove. A residue was then observed on the outside of the pot. Interview with KM #237
verified that the pot was dirty.
Observation on 04/29/25 at 12:27 A.M. revealed DC #214 scoop a serving of white rice on top of a green
residue that was on the plate. DC #214 scraped the rice into the trash to reveal that a green residue was on
the plate. DC #214 confirmed that the plate was dirty.
Observation of the dish machine on 04/29/25 at 1:25 P.M. revealed that the water temperature gage was at
115 degrees Fahrenheit for the entire cycle. KM #237 tested the chlorine sanitizer in the dish machine and
the test strip appeared to be a light purple. Interview with KM #237 verified that the water temperature gage
seemed to be stuck at 115 degrees Fahrenheit and the concentration of the chlorine was at 25 PPM.
Observation of lunch service on 04/29/25 at 12:14 P.M., revealed Dietary Aide (DA) #284 lift the lid of the
trash can to throw away disposable gloves. DA #284 then began assembling items for the lunch trays,
including handling silverware, cups and plates without washing her hands.
Interview with DA #284 on 04/29/25 at 12:18 P.M., confirmed that she did throw away a pair of disposable
gloves and then touch clean kitchen utensils without washing her hands in between. When DA #284 was
asked when staff should be washing their hands, she stated that hands should be washed as needed.
Interview with the Kitchen Manger #237 #237 on 04/29/25 at 12:19 P.M. confirmed that staff should be
washing their hands after touching the lid of the trash can.
Review of the undated policy titled Hand Washing revealed hands and exposed portions of arms should be
washed after handling soiled equipment or utensils.
Review of the undated policy titled, Low Temperature Door Machine revealed that sanitization solution
should be tested three times a day and be 50-100 PPM. Further review of the policy revealed that the dish
machine water temperatures should be between 120-140 degrees Fahrenheit.
Review of the undated policy titled Food Storage revealed containers for bulk items (flour, sugar, etc.) are to
be stored and sealed in a leak proof container with a date and label.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 51 of 61
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
05/01/2025
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)
F 0825
Provide or get specialized rehabilitative services as required for a resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, family interview, and staff interviews, the facility failed to ensure therapeutic
rehabilitation services were provided as ordered. This affected one (#366) of one resident reviewed for
reviewed for therapy services. Facility census was 65.
Residents Affected - Few
Findings include
Review of the closed medical record for Resident #366 revealed an admission date of 02/19/25 and
discharge 03/28/25. Diagnoses included cellulitis, kidney disease, mood disorder, and diabetes.
Review of Hospital referral dated 02/18/25 revealed resident needed skilled rehab stay for wounds and
therapy (Physical and Occupational).
Review of physician orders dated 02/19/25 for Physical/Occupational/Speech therapy (PT/OT/ST) to
evaluate and treat.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #366 was cognitively
intact with a Brief Interview Mental Status (BIMS) of 13 and was dependant with toileting, substantial
/maximum assistance with oral hygiene, bathing, dressing and personal hygiene.
Interview on 05/01/25 at 9:52 A.M., with Therapy Director (TD) #229 revealed when Resident #366
admitted , she was seen by Physical Therapy, but was unable to see Occupational Therapy (OT) due to not
having staffing. TD #229 confirmed the facility had no Occupational Therapist for evaluations of unskilled
residents and revealed they had a staff they brought in only for skilled evaluations. TD #229 revealed they
were about to start OT services when resident discharged after hiring a new Occupational Therapist and
confirmed resident had an order for PT/OT eval and treat and met criteria and approval to begin OT
services once staffing could meet the need.
Interview on 05/01/25 at 10:20 A.M., with Regional Nurse #500 confirmed residents should be receiving
therapy if admitted for therapy and if an eval is ordered and is needed it should be done. Regional Nurse
#500 acknowledged staffing was not a sufficient reason to not provide needed services.
Interview on 05/01/25 around 2:00 P.M., with Resident #366's family revealed the resident was not provided
the therapy they were promised at admission.
This deficiency represents the noncompliance investigated under Complaint Number OH00164520.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 52 of 61
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
05/01/2025
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)
F 0847
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the medical record, resident interview, staff interview, and review of the arbitration agreement, the
facility failed to ensure residents understood the arbitration agreement in a simple manner for residents to
understand. This affected three (#4, #10, and #57) of 39 residents who had arbitration. The facility census
was 65.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #4 revealed an admission date of 01/15/24. Diagnoses
included type two diabetes mellitus (DM II), schizophrenia, and hypertension.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had
intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had
intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15.
Review of the arbitration agreement dated 01/16/24 revealed Resident #4 signed the arbitration agreement.
Interview on 05/01/25 at 9:01 A.M., with Resident #4 revealed he was not explained what he was signing
and wouldn't have signed the arbitration agreement if it was explained to him correctly.
Interview on 05/01/25 at 9:16 A.M., with Admissions Director (AD) #309 verified she doesn't explain to
residents that they are waiving their right to take the facility to court in a language that they understand.
2. Review of the medical record for Resident #10 revealed an admission date of 01/15/25. Diagnoses
included schizophrenia, type two diabetes mellitus (DM II), and mood disorder.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had
intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 13.
Review of the arbitration agreement dated 01/24/25 revealed Resident #10 signed the arbitration
agreement.
Interview on 05/01/25 at 9:22 A.M., with Resident #10 revealed she did not recall signing the arbitration
agreement and was not explained what she was signing. Resident #10 verified she would have not signed
the arbitration agreement.
Interview on 05/01/25 at 9:16 A.M., with Admissions Director (AD) #309 verified she doesn't explain to
residents that they are waiving their right to take the facility to court in a language that they understand.
3. Review of the medical record for Resident #57 revealed an admission date of 03/24/25. Diagnoses
included type two diabetes mellitus (DM II), generalized anxiety disorder (GAD), and major
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 53 of 61
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
05/01/2025
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)
F 0847
depressive disorder.
Level of Harm - Minimal harm
or potential for actual harm
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had
intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15.
Residents Affected - Few
Interview on 05/01/25 at 8:20 A.M., with Resident #309 revealed she was not informed that she signed the
arbitration agreement or explained what she was signing. Resident #309 stated she would have not signed
the arbitration agreement if explained correctly.
Interview on 05/01/25 at 9:16 A.M., with Admissions Director (AD) #309 verified she doesn't explain to
residents that they are waiving their right to take the facility to court in a language that they understand.
Review of the optional arbitration agreement revealed the following: by signing this arbitration agreement,
the resident and the facility were waiving the right to a jury trial for any dispute disagreement, controversy,
demand, or claim and agree that the arbitrator's decision binds both parties and was final.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 54 of 61
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
05/01/2025
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, medical record review, staff interview and review of facility policy, the facility failed to
ensure staff performed hand hygiene after providing resident care. This affected two residents (#7 and
#266). Additionally, the facility failed to ensure proper disposal of personal protective equipment (PPE)
following care provided to Resident #7, who was on enhanced barrier precautions (EBP). This affected two
residents (#7 and #266) of two residents reviewed for infection control. The facility census was 65.
Residents Affected - Few
Findings included:
1. Medical record review for Resident #7 revealed an admission date of 12/30/22. Diagnoses included
arteriosclerotic heart disease, schizophrenia, Alzheimer's disease, diabetes, chronic kidney disease, and
convulsions.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/08/25, revealed Resident #7 was
severely cognitively impaired. His functional status was setup or clean-up assistance for eating,
substantial/maximal assistance for toileting, and supervision or touching assistance for bed mobility and
transfers. Resident #7 was always incontinent of bladder and had a colostomy.
Review of a physician order dated 03/01/25 revealed Resident #7 was in enhanced barrier precautions
(EBP) due to a wound and colostomy.
Observation on 04/28/25 at 2:00 P.M. of incontinence care for Resident #7, provided by Certified Nursing
Aide (CNA) #230, revealed CNA #230 donned a gown and gloves to provide care. After providing care,
Resident #7 asked CNA #230 to get a piece of candy from the drawer next to his bed. While still wearing
the gloves and gown used to provide incontinence care, CNA #230 opened the drawer, reached in, and
removed a candy bar from the drawer. CNA #230 asked Resident #7 if he wanted her to open the candy
bar for him, to which he replied yes. With her gloved hands, CNA #230 opened the candy bar and provided
it to Resident #7.
Interview with CNA #230 on 04/28/25 at 2:15 P.M. confirmed she was still wearing the soiled gloves from
providing incontinence care for Resident #7 and did not perform hand hygiene before touching the
resident's drawer and candy bar.
Additional observation on 04/30/25 at 11:50 A.M. revealed CNA #230 donned gloves and a gown and
assisted Resident #7 out of bed. CNA #230 used her hands to assist the resident up in bed and then
assisted him to stand up to the walker. CNA #230 pulled Resident #7's pants up. Before exiting the
resident's room, CNA #230 removed her gown and gloves and tucked them under her arm. CNA #230 did
not wash her hands. CNA #230 proceeded out of Resident #7's room and entered the room next door. CNA
#230 pulled the privacy curtain closed with her unwashed hands. CNA #230 exited the room, with the
soiled PPE still tucked under her arm.
Interview with CNA #230 on 04/30/25 at 11:55 A.M. confirmed she placed the soiled PPE under her arm,
did not perform hand hygiene, entered the room next to Resident #7's, touched the privacy curtain, exited
that room and still did not wash her hands. At this time, CNA #230 used hand sanitizer.
2. Review of the medical record for Resident #266 revealed an admission date of 01/06/23. Diagnoses
included Alzheimer's disease, Parkinson's disease, anxiety disorder, and type two diabetes mellitus
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 55 of 61
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
05/01/2025
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)
F 0880
(DM II).
Level of Harm - Minimal harm
or potential for actual harm
Review of the quarterly MDS assessment, dated 02/06/25, revealed Resident #266 had moderate cognitive
impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of nine. Resident #266
required partial assistance with toileting and transfers, was staff dependent with bathing, and required
substantial assistance with dressing.
Residents Affected - Few
Observation on 04/30/25 at 1:49 P.M. of catheter care provided for Resident #266 by CNA #256 revealed
the CNA donned gloves to provide care. After care was completed, while still wearing the gloves used to
provide catheter care, CNA #256 touched the bed controller, sheets, and Resident #266's head to
rearrange the pillow.
Interview on 04/30/25 at 2:14 P.M. with CNA #256 verified she did not remove her soiled gloves or perform
hand hygiene before touching Resident #266's head, pillow, and other clean areas in the resident's room.
Review of the facility policy titled, Handwashing, dated 10/01/23, revealed hand hygiene was indicated
immediately before touching a resident; before performing an aseptic task (for example, placing an
indwelling device or handling an invasive medical device; after contact with blood, body fluids, or
contaminated surfaces; after touching a resident; after touching the resident's environment; before moving
from work on a soiled body site to a clean body site on the same resident; and immediately after glove
removal.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 56 of 61
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
05/01/2025
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)
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, staff interview and review of facility policy, the facility failed to ensure
influenza (flu) and pneumococcal vaccinations were offered to residents and further failed to ensure
education on the vaccinations was provided to residents and/or their representatives. This affected one
resident (#7) of five residents reviewed for vaccination status. The facility census was 65.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #7 revealed an admission date of 02/19/20. Diagnoses included
heart disease, schizophrenia, diabetes, Alzheimer's disease and kidney disease.
Review of the Minimum Data Set (MDS) assessment, dated 03/08/25, revealed Resident #7 was severely
cognitively impaired.
Further review of the medical record revealed no evidence Resident #7 was offered or received the flu or
pneumococcal vaccinations or that the resident or resident representative received education on the
vaccination.
Interview on 05/01/25 at 8:39 A.M. with the Director of Nursing (DON) verified the facility had no evidence
of the flu and pneumococcal vaccinations being offered or administered to Resident #7 and further
confirmed the facility had no evidence of education provided to the resident or the resident's representative
related to the vaccinations.
Review of the facility policy titled, Influenza Vaccine, dated 03/22, revealed all residents shall be offered the
flu vaccine each year from October to March, unless contraindicated.
Review of the facility policy titled, Pneumococcal Vaccine, dated 10/23, revealed all residents shall be
offered the pneumococcal vaccine within 30 days of admission unless contraindicated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 57 of 61
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
05/01/2025
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)
F 0887
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and
staff after education, and properly document each resident and staff member's vaccination status.
Based on medical record review, staff interview and review of facility policy, the facility failed to ensure
COVID-19 vaccines were offered to residents, failed to ensure education was provided related to the
vaccination, and further failed to ensure vaccines were administered as consented to. Additionally, the
facility failed to ensure COVID-19 vaccination consent forms were thoroughly and accurately completed to
reflect resident decisions related to the vaccination. This affected four (#7, #30, #33, and #53) of five
residents reviewed for COVID-19 vaccination status. The facility census was 65.
Findings include
1. Review of the medical record for Resident #7 revealed an admission date of 02/19/20. Diagnoses
included heart disease, schizophrenia, diabetes, Alzheimer's disease and kidney disease.
Review of the Minimum Data Set (MDS) assessment, dated 03/08/25, revealed Resident #7 was cognitively
impaired.
Further review of the medical record revealed no evidence Resident #7 was offered or received the
COVID-19 vaccination. Additionally, the medical record revealed no evidence the resident or the resident's
representative were offered the vaccination or received education on the COVID-19 vaccination.
Interview on 05/01/25 at 8:39 A.M. with the Director of Nursing (DON) confirmed the facility had no
evidence Resident #7 was offered or received the COVID-19 vaccination or evidence the resident or
resident representative received education on the vaccine.
2. Review of the medical record for Resident #30 revealed an admission date of 08/13/24. Diagnoses
included pneumonia, malnutrition, hemiplegia, heart failure, vascular disease, and respiratory failure.
Review of the MDS assessment, dated 02/20/25, revealed Resident #30 had moderate cognitive
impairment.
Review of the COVID-19 vaccination consent form revealed it was signed and consented for on 10/12/24.
Review of a physician order dated 11/06/24 revealed the COVID-19 vaccine was ordered for Resident #30.
Further review of the medical record revealed no evidence the COVID-19 vaccine was administered to
Resident #30, as consented to.
Interview on 05/01/25 at 8:39 A.M., with the DON confirmed facility had no evidence Resident #30 received
the COVID-19 vaccine.
3. Review of the medical record for Resident #33 revealed an admission date of 09/19/24. Diagnoses
included sepsis, diabetes, and vascular disease.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 58 of 61
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
05/01/2025
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)
F 0887
Review of the MDS assessment, dated 03/27/25, revealed Resident #33 was moderately cognitively
impaired.
Level of Harm - Minimal harm
or potential for actual harm
Review of the COVID-19 vaccination consent form revealed it was signed and consented to on 10/11/24.
Residents Affected - Some
Review of the physician orders revealed no evidence the COVID-19 vaccine was ordered for Resident #33.
Further review of the medical record revealed no evidence Resident #33 was administered the COVID-19
vaccine, as consented to.
Interview on 05/01/25 at 8:39 A.M. with the DON confirmed facility had no evidence Resident #33 received
the COVID vaccine.
4. Review of the medical record for Resident #53 revealed an admission date of 08/13/24. Diagnoses
included dementia, malnutrition, depression, emphysema and syncope.
Review of the MDS assessment, dated 02/20/25, revealed Resident #53 had moderate cognitive
impairment.
Review of COVID-19 vaccination consent form revealed it was signed, but had no date and none of the
boxes were checked to indicate whether the vaccination was consented to or declined.
Further review of the medical record revealed no evidence Resident #53 was administered the COVID-19
vaccination.
Interviews on 04/30/25 from 4:47 P.M. to 6:49 P.M. with Regional Nurse (RN) #500 and RN #508 revealed
COVID-19 vaccination consents should be dated to verify when they were offered and ensure timeliness.
RN #500 and RN #508 verified Resident #53's vaccination consent was undated and did not indicate the
resident or resident representative's decision on receiving the vaccination.
Review of the facility policy titled, Coronavirus Disease (COVID-19) - Vaccination of Residents, dated 05/23,
revealed residents shall be offered the COVID-19 vaccine. The vaccination administration shall be
documented in the medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 59 of 61
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
05/01/2025
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)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation, staff interview, medical record review and review of facility policy, the facility failed to
ensure resident bathrooms were free from odors for five (#7, #18, #37, #51, and #60) five residents
reviewed for clean and sanitary bathrooms. Additionally, the facility failed to ensure the corridors were free
from pervasive odors. This affected all residents except for 16 residents (#2, #5, #6, #8, #14, #22, #23, #33,
#39, #40, #41, #43, #52, #56, #58, #62) identified as living on the rehabilitation unit. The facility census was
65.
Findings included:
1. Medical record review for Resident #7 revealed an admission date of 12/30/22. Diagnoses included
arteriosclerotic heart disease, schizophrenia, Alzheimer's disease, diabetes, chronic kidney disease, and
convulsions.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/08/25, revealed Resident #7 was
severely cognitively impaired. His functional status was setup or clean-up assistance for eating,
substantial/maximal assistance for toileting, and supervision or touching assistance for bed mobility and
transfers. He was always incontinent of bladder and the resident had a colostomy. Resident #7 had
wandering behaviors.
Observation of Resident #7's bathroom on 05/01/25 at 12:45 P.M. revealed there was a strong urine odor,
with no indication as to the source of the foul odor.
Interview with the Maintenance Director (MD) #300 on 05/01/25 at 1:00 P.M. confirmed the strong urine
odor in Resident #7's bathroom and further verified the source of the odor was unknown.
2. Observations of the facility on 04/28/25 at 9:00 A.M., 04/30/25 at 9:08 A.M. and on 05/01/25 at 6:30 A.M.
revealed a strong urine and body odor throughout all of the halls, except for the rehabilitation unit.
Interview with Certified Nursing Assistant (CNA) #230 on 04/28/35 at 9:00 A.M. confirmed the halls had a
foul odor.
Interview with CNA #254 and CNA #230 on 04/30/25 at 9:10 A.M. confirmed there was a foul odor in the
facility. CNA #230 and CNA #254 stated they did not know how to get rid of the odor, adding they used a
spray but some of the residents did not bathe and they believed that contributed to the odors.
3. Review of the medical record for Resident #51 revealed an admission date of 02/07/25. Diagnoses
included shortness of breath, diabetes, and heart failure. Review of the MDS assessment, dated 02/14/25,
revealed Resident #51 was cognitively intact and required supervision or touching assistance with toileting.
Review of the medical record for Resident #18 revealed an admission date of 05/07/24. Diagnoses included
dementia, Alzheimer's disease, and cognitive communication deficit. Review of the MDS assessment,
dated 02/09/25, revealed Resident #18 was rarely/never understood and required supervision or touching
assistance with toileting.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 60 of 61
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
05/01/2025
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)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of the medical record for Resident #60 revealed an admission date of 04/01/24. Diagnoses included
ataxia, dyspnea, edema and weakness. Review of the MDS assessment, dated 04/10/25, revealed
Resident #60 was cognitively intact and required partial/moderate assistance with toileting.
Review of the medical record for Resident #37 revealed an admission date of 12/31/20. Diagnoses included
myocardial infarction, hemiplegia and hemiparesis, cerebral infarct, heart disease, and vascular dementia.
Review of the MDS assessment, dated 04/20/25, revealed Resident #37 was severely cognitively impaired
and required partial/moderate assistance for toileting.
Observation on 04/28/25 at 10:20 A.M. revealed the shared bathroom for Resident #18, Resident #37,
Resident #51 and Resident #60 had a strong, pungent urine odor and a sticky residue on the floor.
Interview on 04/28/25 at 1:10 P.M. and interview on 04/28/25 at 1:10 P.M. with MD #300 confirmed the
bathroom had a strong, foul urine odor and a sticky residue on the floor.
Review of the facility policy titled, Homelike Environment, dated 02/21, revealed residents shall be provided
a clean and comfortable environment. The facility shall provide a homelike setting that was clean with
pleasant neutral scents.
This deficiency represents the noncompliance investigated under Complaint Numbers OH00164520 and
OH00164238.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366236
If continuation sheet
Page 61 of 61
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Back to topCitations
28 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F567 - The resident has a right to manage his or her financial affairs
Honor the resident's right to manage his or her financial affairs.
F576 - The resident has the right to have reasonable access to the use of a telephone,
Ensure residents have reasonable access to and privacy in their use of communication methods.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F605 - Respect and Dignity
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F825 - Specialized rehabilitative services
Provide or get specialized rehabilitative services as required for a resident.
F847 - Entering Into Binding Arbitration Agreements
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the May 1, 2025 survey of GOOD SHEPHERD VILLAGE?
This was a inspection survey of GOOD SHEPHERD VILLAGE on May 1, 2025. The surveyor cited 28 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GOOD SHEPHERD VILLAGE on May 1, 2025?
Yes, 28 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to manage his or her financial affairs."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.