Inspection Reports for Good Shepherd Lutheran Community

This document serves to verify that Good Shepherd Lutheran Home's SNF/NF dual certification license is valid through the renewal date and includes the nursing home licensure renewal application.

The document confirms licensure renewal status and includes ownership information, facility capacity, and accreditation certifications. No inspection findings or deficiencies are reported.

The document is a Nursing Home Licensure Renewal Application and certification verifying that Good Shepherd Lutheran Home is licensed through the renewal date indicated on the renewal card.

The document confirms that Good Shepherd Lutheran Home meets statutory requirements for SNF/NF dual certification and includes licensure renewal information, ownership details, and certification of compliance with applicable rules and regulations.

The document is a Nursing Home Licensure Renewal Application and certification verifying that Good Shepherd Lutheran Home is licensed through the date indicated on the renewal card.

The document certifies that Good Shepherd Lutheran Home meets statutory requirements for licensure renewal as a skilled nursing facility with specified therapy services. It includes ownership, accreditation, and facility capacity details.

This document serves as a license renewal certification and renewal application for Good Shepherd Lutheran Home, verifying the facility's licensure status and capacity.

The documents confirm that Good Shepherd Lutheran Home meets statutory requirements for SNF/NF dual certification with a licensed capacity of 84 beds and a current census of 56 residents.

An unannounced visit was conducted to investigate a complaint at Good Shepherd Lutheran Home regarding allegations that the facility failed to follow practitioner's orders, ensure residents had access to call lights, and assist residents with pain management.

The investigation found that the facility was in compliance with relevant regulations for all allegations: practitioners' orders were followed, residents had access to call lights, and residents were assisted with pain management.

The complaint allegations were not substantiated as the facility was found compliant in all areas investigated.

An unannounced visit was conducted to investigate a complaint that the facility fails to provide care and services to prevent injury.

The facility was found to provide care and services to prevent injury based on interviews, record reviews, and observations. The residents were receiving interventions to prevent injuries, and the facility was in compliance with regulations.

The complaint alleged failure to provide care and services to prevent injury. The allegation was not substantiated as the facility was found in compliance.

An unannounced visit was conducted to investigate a complaint and annual survey at Good Shepherd Lutheran Home on June 18-21, 2018, by representatives of the Department of Health and Human Services Division of Public Health.

The complaint investigation found the facility was in compliance with allegations related to injury prevention, property accounting, and resident dignity. A late report of neglect was identified but no deficiency was written due to corrective action. The annual survey identified multiple deficiencies related to immunizations, life safety code violations including means of egress, fire safety, emergency lighting, fire alarm and sprinkler systems, fire drills, and electrical safety.

The complaint allegations included failure to put interventions in place to prevent injuries, failure to ensure residents' property is accounted for, failure to treat residents with respect and dignity, and failure to immediately report allegations of abuse. The facility was found compliant on all but one late reporting of neglect allegation, which was corrected and no deficiency was cited.

The document is a Nursing Home Licensure Renewal Application and related materials for Good Shepherd Lutheran Home, indicating the facility's license renewal process and certification status.

The documents confirm the facility's licensure renewal status, bed certifications, and occupancy permit. No inspection deficiencies or findings are reported.

The notice was issued to inform Good Shepherd Lutheran Home of disciplinary action placing their license on probation for 180 days starting June 28, 2017, due to failure to identify causal factors to prevent resident falls.

The facility violated licensure regulations related to accidents by failing to identify causal factors to prevent resident falls, resulting in probation and requirements to submit a Plan of Correction and biweekly reports on residents with accidents.

An unannounced visit was conducted to investigate a complaint survey at Good Shepherd Lutheran Home regarding failure to investigate causative factors in falls and effectiveness of elopement prevention interventions.

The facility failed to investigate causative factors following resident falls affecting 3 of 4 residents reviewed, with no interventions put in place to prevent recurrence. Interventions to prevent elopement were found to be effective with no violation. The facility census was 72.

The complaint alleged the facility failed to investigate causative factors in falls and failed to ensure interventions were effective in elopement prevention. The investigation confirmed failure in fall investigations but found no violation regarding elopement prevention.

An unannounced visit was conducted to investigate a complaint and annual survey at Good Shepherd Lutheran Home on April 17-20, 2017 by the Department of Health and Human Services Division of Public Health.

The facility was found to be in compliance with staff credential requirements. Deficiencies were cited related to failure to notify physician of significant weight loss, housekeeping and maintenance issues, incomplete comprehensive assessments and care plans, failure to maintain nutrition status, unnecessary drug use, food service sanitation, medication storage and labeling, fire safety code violations including means of egress obstructions, fire door malfunctions, sprinkler system issues, emergency lighting deficiencies, electrical system problems, and lack of staff training on fire safety procedures.

Complaint allegation was that the facility failed to ensure staff had required credentials. The facility was found to be in compliance with this allegation.

The document is a renewal application and certification for the nursing home license of Good Shepherd Lutheran Home, verifying licensure through the indicated renewal date.

The facility is licensed as a Skilled Nursing Facility/Nursing Facility dual certification with a total licensed capacity of 84 beds. The renewal application certifies compliance with Nebraska Department of Health and Human Services rules and regulations.

The notice serves to inform the facility of disciplinary action placing its license on probation for 90 days starting January 13, 2017, due to violations related to resident safety and failure to comply with licensure regulations.

The facility was found to have violated licensure regulations by failing to transfer a resident safely, resulting in a fall and injury. The probation requires submission of a Plan of Correction and periodic reports on residents with accidents.

An unannounced visit was conducted to investigate a complaint survey regarding failure to protect residents from injury at Good Shepherd Lutheran Home.

The facility failed to protect residents from injury by not transferring one resident safely, resulting in a fall with a fracture, and failed to report and protect a resident from abuse by a roommate. The facility was found in violation of Federal regulation F323 and 175 NAC 12-006.09D7.

The complaint alleged the facility failed to protect residents from injury. The investigation confirmed that Resident 5 was physically abused by a roommate and the incident was not reported timely or managed properly. Resident 1 was transferred unsafely resulting in a fall and fracture.

An unannounced visit was conducted to investigate a complaint regarding the facility's failure to provide care and treatment to prevent skin breakdown and to treat residents with dignity and respect.

The facility was found to be in compliance with all related regulatory requirements. Observations, resident and staff interviews, and record reviews showed that care to prevent skin breakdown was provided and residents were treated with dignity and respect.

The complaint alleged failure to provide care to prevent skin breakdown and failure to treat residents with dignity and respect. Both allegations were found to be unsubstantiated.

An unannounced visit was conducted to investigate a complaint regarding the facility's failure to provide prompt cardio-pulmonary resuscitation and failure to answer call notification systems promptly.

The facility failed to provide prompt cardio-pulmonary resuscitation in one case due to difficulty determining CPR wishes, but took immediate corrective actions including staff education and policy revision. The facility was found to respond promptly to call notification systems and was in compliance with regulatory guidelines.

The complaint alleged failure to provide prompt cardio-pulmonary resuscitation and failure to answer call notification systems promptly. The CPR allegation was substantiated with findings, but the facility self-corrected and no citation was issued. The call system allegation was not substantiated.

An unannounced visit was conducted to investigate a complaint regarding the facility's failure to provide prompt cardio-pulmonary resuscitation and failure to answer call notification systems promptly.

The facility failed to provide prompt CPR in one case due to difficulty determining CPR wishes but had self-corrected with staff education and policy revision, resulting in no citation. The facility was found to respond promptly to call notification systems and was in compliance with regulatory guidelines. Additionally, a separate deficiency was found related to incomplete criminal background checks for one employee, which was addressed with new policies and audits.

The complaint alleged failure to provide prompt CPR and failure to answer call notification systems promptly. The CPR allegation was substantiated with findings but self-corrected by the facility. The call system allegation was not substantiated.

An unannounced visit was conducted to investigate a complaint regarding the facility's failure to give appropriate discharge notice and failure to notify practitioners of families' requests for medication changes/review.

The facility was found to be in compliance with regulatory guidelines for both allegations. Appropriate discharge notice was given, and practitioners were notified of families' requests for medication changes/review.

The complaint alleged failure to give appropriate discharge notice and failure to notify practitioners of families' requests for medication changes/review. Both allegations were found to be unsubstantiated as the facility complied with regulatory requirements.

An unannounced visit was conducted to investigate a complaint regarding failure to protect residents from residents with behaviors and failure to implement new interventions after accidents with injury.

The facility was found to have failed to develop a comprehensive care plan addressing behaviors for one resident and failed to update care plans with new interventions after a fall for another resident. Additionally, the facility failed to ensure interventions were implemented to prevent accidents, including proper placement of call lights and personal alarms.

The complaint alleged the facility failed to protect residents from residents with behaviors and failed to implement new interventions after accidents with injury. The investigation found the facility did protect residents from behaviors but failed to develop a care plan for one resident exhibiting behaviors and failed to update care plans and implement interventions after falls for other residents.

An unannounced visit was conducted to investigate a complaint and annual survey at Good Shepherd Lutheran Home from March 16, 2016 to March 22, 2016. The complaint alleged the facility failed to protect residents from residents with behaviors.

The facility was found to protect residents from residents with adverse behaviors with no violation related to the allegation. Observations, interviews, and record reviews showed staff used effective calming and intervention techniques, and care plans addressed behavioral needs. The facility was in compliance with relevant regulatory requirements.

The complaint alleged the facility failed to protect residents from residents with behaviors. The investigation found no violation related to this allegation; the facility was compliant.

An unannounced visit was conducted to investigate a complaint alleging the facility failed to identify underlying causes and implement individualized approaches for residents with aggressive behaviors.

The facility was found to identify underlying causes and implement individualized approaches for residents with aggressive behaviors. Observations, staff interviews, and record reviews confirmed compliance with related regulatory requirements.

The complaint alleged failure to identify underlying causes and implement individualized approaches for residents with aggressive behaviors. The complaint was determined to be unsubstantiated as the facility was in compliance.

An unannounced visit was conducted to investigate a complaint at Good Shepherd Lutheran Home on August 26-27, 2015, including a special focus dementia survey.

The facility was found in violation of multiple regulations including failure to notify physicians of medication errors and infections, inaccurate assessments, failure to revise care plans for behavioral issues, failure to provide necessary care and supervision, and unsafe environment hazards such as hot beverage dispensers accessible to residents with dementia.

The complaint investigation included allegations related to dementia care and medication errors. The facility was found in violation of multiple federal regulations related to notification of changes, assessment accuracy, care planning, provision of care, safety hazards, and quality assurance.

An unannounced visit was conducted to investigate a complaint at Good Shepherd Lutheran Home regarding failure to provide care to prevent incontinence, retaliation against residents after complaints, and prevention of skin breakdown.

The facility was found to be in compliance with regulatory guidelines for all allegations investigated, including care to prevent incontinence, prevention of retaliation against residents, and prevention of skin breakdown.

The investigation addressed three allegations: failure to prevent incontinence, failure to prevent retaliation against residents after complaints, and failure to prevent skin breakdown. All allegations were found to be unsubstantiated with the facility in compliance.

An unannounced visit was conducted to investigate a complaint and annual survey at Good Shepherd Lutheran Home on April 15, 2015-April 21, 2015, triggered by an allegation that the facility failed to submit investigations within 5 working days.

The facility was found to be in compliance with submitting investigations within 5 working days. The facility census was 71. Additional findings included deficiencies in resident bathing preferences, comprehensive care plans for dental and incontinence care, pressure sore prevention, urinary incontinence interventions, fall prevention, and dental services. Life safety code deficiencies were also identified including fire door obstructions, exit obstructions, fire door maintenance, exit sign failures, sprinkler system maintenance, fire extinguisher inspections, and kitchen hood cleaning.

The complaint alleged the facility failed to submit investigations within 5 working days. The investigation found the facility did submit investigations timely and was in compliance.

An unannounced visit was conducted to investigate a complaint alleging that the facility fails to put interventions in place to prevent injuries.

The facility was found to have interventions in place to prevent injuries. Review of three resident records, observations, and staff interviews confirmed care plans were updated and interventions were implemented, resulting in compliance with regulatory requirements.

The complaint alleged failure to put interventions in place to prevent injuries. The facility was found to be in compliance and no deficiencies were cited.

An unannounced visit was conducted to investigate a complaint regarding the facility's failure to monitor and/or reevaluate interventions to prevent resident elopements.

The facility did monitor and reevaluate interventions to prevent resident elopements, based on review of three active resident records requiring alarms and staff interviews.

The allegation was that the facility failed to monitor and/or reevaluate interventions to prevent resident elopements. The investigation found the facility was compliant in this regard.

An unannounced visit was conducted to investigate a complaint regarding failure to protect residents from adverse behaviors, failure to submit investigations timely, failure to evaluate non-pharmacological interventions before anti-psychotic medications, failure to protect residents from misappropriation, and failure to ensure residents are not chemically restrained.

The facility was found to have failed to ensure a resident's narcotic medication was not used for another resident, failed to submit investigations to the state agency within required time frames, and failed to protect residents from misappropriation of medication. The facility did protect residents from adverse behaviors and chemical restraints. Medication storage and narcotic count procedures were deficient.

The complaint alleged failure to protect residents from residents with adverse behaviors, failure to submit investigations timely, failure to evaluate non-pharmacological interventions before anti-psychotic medications, failure to protect residents from misappropriation, and failure to ensure residents are not chemically restrained. The facility was substantiated for failure to protect from misappropriation and failure to submit investigations timely.

An unannounced visit was conducted to investigate a complaint alleging the facility failed to ensure residents were free from abuse and failed to investigate allegations of abuse.

The facility ensured residents were free from abuse and properly investigated allegations of abuse, with no violations found at the time of the survey. Staff and residents demonstrated knowledge of abuse reporting procedures.

The complaint alleged failure to ensure residents were free from abuse and failure to investigate allegations of abuse. The allegations were not substantiated.

An unannounced visit was conducted to investigate a complaint regarding the facility's failure to use appropriate interventions to prevent injuries.

The facility implemented interventions to prevent injuries, including care plans for residents at risk for falls, evaluation of falls for causal factors, and weekly fall committee meetings. The facility was determined to be in compliance with related regulatory requirements.

The complaint alleged the facility failed to use appropriate interventions to prevent injuries. The investigation found the facility was in compliance with regulatory requirements related to injury prevention.

The document serves as a Notice of Disciplinary Action against Good Shepherd Lutheran Home for violations related to failure to evaluate causal factors and prevent pressure ulcers, placing the facility on probation for 90 days starting June 14, 2014.

The facility failed to evaluate causal factors, monitor, and re-evaluate interventions to promote healing and prevent further pressure ulcers, resulting in disciplinary action and probation.

An unannounced visit was conducted to investigate a complaint and annual survey at Good Shepherd Lutheran Home on May 5, 2014-May 8, 2014.

The complaint investigation found failures in providing interventions to protect residents from injury, supervision as identified in the plan of care, and providing a safe environment for residents at risk for elopement. The facility also failed to ensure privacy during personal cares, dignity in applying undergarments, assistance with eating, treatment and monitoring of pressure ulcers, medication error rate less than 5%, posting nurse staffing information, maintaining sanitary kitchen conditions, follow-up on dental care, expired lab vials, and quality assurance program effectiveness. Life safety code deficiencies were also identified including fire safety compartment separation, exit access, illumination, fire alarm system maintenance, sprinkler system maintenance, fire extinguisher inspection, kitchen suppression system inspection, emergency generator testing, and electrical equipment use.

The complaint investigation found allegations that the facility failed to provide residents a safe place to keep personal belongings, protect residents from misappropriation, put interventions in place to protect residents from injury, ensure residents were supervised as identified in the plan of care, and provide a safe environment for residents at risk for elopement. Findings substantiated failures in interventions to prevent injury, supervision, and safe environment for elopement.

The inspection was conducted to assess compliance with medication error rates and other regulatory requirements for skilled nursing facilities as per Nebraska Administrative Code.

The facility failed to maintain a medication error rate of five percent or less, with a 9.5% error rate involving one resident receiving medications orally that should have been administered via J-tube. The Director of Nursing confirmed the medication error and the lack of proper medication orders.

The inspection was conducted to investigate an allegation of abuse involving a nurse aide and a resident at Good Shepherd Lutheran Home.

The facility failed to report an allegation of abuse involving Nurse Aide A calling Resident 1 an 'ass' to Adult Protective Services (APS) and did not forward an investigation report to the survey agency within the required 5 working days. The Administrator did not report the allegation as they felt it was not correct.

The complaint involved an allegation that Nurse Aide A called Resident 1 an 'ass' and used a sit-stand lift to transfer the resident. Resident 1 confirmed the allegation. The facility did not report the allegation to APS or the survey agency within 5 working days as required. The Administrator acknowledged the failure to report, stating the allegation was not correct.

The inspection was conducted as an annual survey to assess compliance with regulatory requirements including life safety, comprehensive assessments, care planning, infection control, medication management, and facility safety.

The facility had multiple deficiencies including failure to maintain emergency exit signs, incomplete comprehensive assessments, inadequate care planning especially related to discharge and behaviors, failure to evaluate catheter use, fire safety code violations including sprinkler system and fire alarm maintenance, infection control lapses, medication regimen issues, and quality assurance program deficiencies.

Routine inspection of Good Shepherd Lutheran Home to assess compliance with Nebraska Administrative Code regulations governing licensure of skilled nursing facilities, focusing on care plan revisions and fall prevention.

The facility failed to revise care plan interventions for three residents related to falls and failed to ensure a safe environment free of accident hazards, including supervision and use of assistive devices. Personal alarms were found unplugged during falls, and care plans were not updated after individual falls.

Annual inspection of Good Shepherd Lutheran Home to assess compliance with Nebraska Administrative Code and federal regulations including licensure, life safety, infection control, and other health and safety standards.

The facility was found deficient in multiple areas including failure to report abuse allegations timely, maintenance issues such as gouged doors, inadequate pressure ulcer care, improper use and monitoring of psychoactive drugs, Director of Nursing working as charge nurse despite census over 60, plumbing and food safety violations, hand hygiene lapses, lack of emergency water supply procedures, fire safety code violations including blocked fire doors, missing sprinkler heads, and electrical code violations.

This document serves to verify that Good Shepherd Lutheran Home's SNF/NF Dual Certification license is renewed and valid through the date indicated on the renewal card.

The document confirms that the facility meets statutory requirements for SNF/NF Dual Certification and is licensed for 84 beds. It includes ownership, accreditation, and certification details, as well as a Nebraska State Fire Marshal occupancy permit.

This document serves as a licensure renewal application and verification for Good Shepherd Lutheran Home, confirming the facility's license status and renewal fees.

The documents confirm the facility meets statutory requirements for licensure renewal and includes a temporary occupancy permit with a maximum occupancy of 84 beds.

This document package serves as a license renewal certification and application for Good Shepherd Lutheran Home, verifying licensure through the renewal date and providing ownership and occupancy information.

No inspection findings are reported; the documents confirm licensure renewal, ownership details, and occupancy permit compliance for the facility.

The notice serves to inform the facility of disciplinary action placing its license on probation for 90 days starting May 17, 2017, due to violations including failure to identify significant weight loss and implement interventions to prevent further weight loss.

The facility was found in violation of several licensure regulations related to resident assessment, care provision, housekeeping, dietary services, and medication storage, specifically failing to identify and address unplanned weight loss among residents.

This document serves as a license renewal application for Good Shepherd Lutheran Home and includes facility policies, procedures, and descriptions related to the Special Care Unit and dementia care.

The document includes certification of licensure renewal, occupancy permit details, facility policies on dementia care and special care units, staff training, family support programs, and daily room rates. No inspection findings or deficiencies are reported.