Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Shepherd The during CMS and state inspections, most recent first.
The facility failed to follow antibiotic stewardship practices, affecting 17 residents. In May and June 2024, several antimicrobial treatments prescribed by the facility's prescribers did not meet criteria for use and were not discontinued. The ADON confirmed the facility did not conduct an antibiotic timeout within 48 to 72 hours of initiation to review the appropriateness of the antibiotics, despite the facility's policy requiring such a review.
A facility failed to properly complete NOMNC and SNF ABN forms for a resident, omitting specific details about the skilled services ending and associated costs. The resident had a history of stroke, dementia, diabetes, and falls. The issue was confirmed by the Director of Social Services and Admissions.
A facility failed to implement a splinting program for a resident with severe cognitive impairment and contractures, as therapy notes indicated the need for hand splints to promote digit extension. Documentation showed inconsistencies in splint application, and observations confirmed the absence of splints over several days. Staff interviews revealed a lack of awareness about the resident's current interventions.
The facility failed to provide appropriate fall interventions for a resident with severe cognitive impairment, relying on ineffective re-education despite multiple falls. Additionally, another resident with a Wander-guard device lacked a physician order, contrary to facility policy. Staff interviews confirmed these deficiencies, highlighting lapses in implementing fall prevention and wander management protocols.
The facility failed to ensure that two residents using CPAP machines had physician orders specifying the machine settings. One resident with asthma, COPD, and morbid obesity used a CPAP without specified settings in the order, while another resident with sleep apnea and heart failure used a CPAP without any documented orders. Staff confirmed the absence of necessary documentation, despite facility policy requiring it.
A resident with type II diabetes, anxiety, and dementia did not receive timely dental care. Despite being cognitively intact, the resident required surgical removal of ankylosed teeth, as noted on a dental assessment. The facility dentist was unable to perform the extraction and planned a referral to an oral surgeon. However, by a later date, the resident had only been seen by a dental hygienist, and the dentist was absent. The resident expressed the need for dental attention, and the DON confirmed that an oral surgeon could not perform the extraction until the following year, with no documentation of contact.
A resident with C. diff was inappropriately exposed to a cleaning chemical not effective against the bacteria. The housekeeper used BNC-15, believing it would kill C. diff, contrary to the facility's policy requiring a bleach-based disinfectant. The housekeeping manager confirmed the error, noting the correct chemical was not used as per the facility's guidelines.
Failure in Antibiotic Stewardship Practices
Penalty
Summary
The facility failed to adhere to antibiotic stewardship practices in prescribing antimicrobials, affecting 17 residents out of 57 entries for antimicrobial treatments initiated in May and June 2024. The infection control tracking for May 2024 revealed 32 antimicrobial treatments, with 21 prescribed by the facility's prescribers. Of these, nine treatments did not meet the criteria for use, and the antimicrobials were not discontinued. In June 2024, 25 antimicrobial treatments were tracked, with 13 prescribed by the facility's prescribers. Of these, 11 treatments did not meet the criteria for use, and the antimicrobials were not discontinued. The Assistant Director of Nursing (ADON) confirmed that the facility used McGeer's criteria to determine the existence of an infection and the need for antimicrobial treatment. However, the facility did not conduct an antibiotic timeout within 48 to 72 hours of initiation to review the appropriateness of the antibiotics. The facility's antibiotic stewardship policy, revised in December 2023, mandates that the Medical Director oversees adherence to antibiotic prescribing practices and that nursing conducts an antibiotic timeout within 48 to 72 hours of antibiotic therapy. Despite these guidelines, the facility failed to follow these practices, leading to inappropriate antimicrobial use.
Deficiency in Beneficiary Notice Completion
Penalty
Summary
The facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) forms contained all necessary information for a resident. The NOMNC provided to the resident's representative did not specify which skilled service was ending. Similarly, the SNF ABN lacked details on the specific skilled service being discontinued and the associated costs if the resident wished to continue receiving those services. Instead, the SNF ABN only listed the facility's semi-private room and board rate. This deficiency was confirmed during an interview with the Director of Social Services and Admissions, who acknowledged the forms were completed incorrectly. The resident involved had a medical history that included a cerebrovascular accident (stroke), dementia, type II diabetes mellitus with diabetic neuropathy, and a history of falls. The facility's census at the time was 119, and this issue affected one of the three residents reviewed for beneficiary notices.
Failure to Implement Splinting Program for Resident
Penalty
Summary
The facility failed to implement a splinting program for a resident to prevent further decrease in range of motion (ROM). The resident, who was admitted with diagnoses including aphasia, metabolic encephalopathy, and contractures, was assessed to have severe cognitive impairment and was fully dependent on staff for daily activities. A therapy note indicated that the resident was to have a rolled splint applied to the right hand and a resting splint for the left hand to promote digit extension, with specific instructions provided to the staff. However, documentation revealed inconsistencies in the application of the splints, with several days in July where the splints were not applied as required. Observations over multiple days confirmed that the splints were not in place on the resident's hands. Interviews with staff, including a State tested Nurse Aide and a Licensed Practical Nurse, confirmed the absence of the splints and a lack of awareness regarding the current interventions for the resident's condition.
Deficiencies in Fall Prevention and Wander Management
Penalty
Summary
The facility failed to ensure appropriate and resident-centered fall interventions for Resident #65, who had a history of cerebrovascular accident, dementia, type II diabetes mellitus with diabetic neuropathy, and a history of falls. Despite being assessed with severely impaired cognition and identified as having a moderate risk for falls, the interventions following multiple falls were limited to re-education on call light usage and self-transfers, which were ineffective due to the resident's cognitive impairment. The resident experienced several falls, including incidents in the common area and her room, with interventions that did not adequately address her needs or prevent further falls. Additionally, the facility did not ensure that residents with Wander-guards had current physician orders for these security devices. Resident #45, who was moderately cognitively impaired and identified as a moderate risk for elopement, was observed with a Wander-guard device on her ankle without a corresponding physician order. This oversight indicates a failure to adhere to the facility's Wander Management policy, which requires physician orders for such devices to be obtained and documented. Interviews with facility staff, including the Assistant Director of Nursing, Staff Development Nurse, and Director of Nursing, confirmed the inadequacy of the interventions for Resident #65 and the lack of physician orders for Resident #45's Wander-guard. The facility's policies on fall prevention and wander management were not effectively implemented, leading to deficiencies in ensuring resident safety and compliance with established protocols.
Failure to Document CPAP Settings and Orders
Penalty
Summary
The facility failed to ensure that residents requiring non-invasive mechanical ventilation through CPAP machines had physician orders specifying the machine settings. This deficiency affected two residents. Resident #09, who had medical diagnoses including asthma, COPD, and morbid obesity, was observed using a CPAP machine without specified settings in the physician's order. The order only mentioned using the CPAP per home settings, and staff, including an LPN and RN Supervisor, confirmed the absence of detailed settings in the order. The facility's respiratory therapy department was responsible for clarifying orders, but the necessary settings were not documented. Similarly, Resident #59, diagnosed with sleep apnea, heart failure, anxiety, and bipolar disorder, was using a CPAP machine without any physician orders documented in the medical record. The resident confirmed regular use of the CPAP machine, and the DON acknowledged the lack of physician orders and documented servicing of the machine, despite the facility's policy requiring such documentation. The facility's policy mandates obtaining an order for CPAP use and settings, as well as documenting the machine's use and the resident's response.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to provide timely dental care for Resident #28, who was admitted with diagnoses including type II diabetes, anxiety, and dementia. The resident was cognitively intact according to the Minimum Data Set (MDS) assessment. On 03/15/24, a dental note indicated the need for a consultation with an oral maxillofacial surgeon due to ankylosed teeth requiring surgical removal. The resident was prescribed Peridex and amoxicillin. However, the facility dentist was unable to extract the tooth and planned to refer the resident to an oral surgeon. By 06/17/24, the resident was seen by a dental hygienist, but the dentist was not present, and issues with two mobile teeth were noted. On 07/16/24, the resident expressed the need to see a dentist for a loose tooth. The Director of Nursing (DON) confirmed on 07/18/24 that communication with an oral surgeon had occurred, but the extraction could not be scheduled until 2025, and there was no documentation of the oral surgeon being contacted.
Improper Cleaning Chemical Used in Isolation Room
Penalty
Summary
The facility failed to use the proper cleaning chemicals in a resident room with isolation precautions, specifically affecting a resident with a diagnosis of Clostridium difficile (C. diff). The resident was admitted with cellulitis of the left lower leg, C. diff, and dementia, and was on the antibiotic vancomycin for C. diff. The plan of care included administering medications as ordered and using appropriate precautions. However, during an observation, a housekeeper was seen mopping the floor in the resident's room using a chemical that was not effective against C. diff. Interviews with the housekeeper and the Housekeeping and Laundry Manager revealed that the housekeeper believed the chemical used, BNC-15, would kill C. diff bacteria, although it was not listed as effective against C. diff. The facility's policy required the use of an EPA-registered, hypochlorite-based disinfectant for cleaning C. diff rooms, which was not followed. The housekeeping manager confirmed that another chemical should have been used for rooms with contact isolation due to C. diff, as per the facility's policy and procedure.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ashland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crystal Care Center Of Ashland | 1.2 mi | — | 4 | 0 |
| Brethren Care Village Health Care Center | 1.2 mi | — | 0 | 0 |
| Kingston Of Ashland | 1.9 mi | — | 3 | 0 |
| Arbors At Mifflin | 9.1 mi | — | 0 | 0 |
| Oak Grove Manor | 9.1 mi | — | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.