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 Services Ltd during CMS and state inspections, most recent first.
A resident with Lewy Body dementia, severe cognitive impairment, and an activated POA for healthcare told a CNA during morning care that they had been raped two days earlier, and repeated the allegation later that morning in front of the AD and DON. The CNA reported the allegation to an LPN and the DON, and the ED was informed during a behavior meeting, but neither law enforcement nor the State Agency were notified, despite facility policy requiring immediate reporting of all abuse allegations to the SA and, as applicable, to outside authorities such as law enforcement and APS.
A resident with Lewy Body dementia, severe cognitive impairment, and an activated POA for healthcare reported to a CNA, the AD, and the DON that the resident had been raped. Although facility policy requires a thorough abuse investigation, including evidence collection, interviews with the alleged victim, other residents, and staff, and possible involvement of law enforcement, the facility did not complete these steps. The DON acknowledged hearing the allegation and performing a skin assessment but confirmed that law enforcement was not notified and that additional staff or resident interviews were not conducted. The ED confirmed that a sexual assault exam was not offered and that staff education on reporting and investigation requirements was not completed.
The facility failed to prevent physical abuse when a cognitively impaired resident with dementia and anxiety disorder twice assaulted other severely cognitively impaired residents. In one incident, an LPN observed the aggressive resident arguing with another resident and forcefully squeezing that resident's wrist, resulting in bruising to the victim's hand and wrist and a bruise and skin tear to the aggressor's hand. In a separate incident, staff saw the same resident extend a leg to trip a wheelchair-bound resident and forcibly grab that resident's hand and wrist, causing pain and two bruises. Both victims had dementia with severely impaired cognition, and staff documentation and interviews confirmed the resident-to-resident altercations and resulting injuries.
A resident with intact cognition and medical conditions including DM2 and rheumatoid arthritis reported, along with their responsible party, that cash and gift cards were missing from the resident’s walker. An agency CNA admitted to taking the money and gift cards. Facility policy requires training and procedures to prevent abuse, neglect, and misappropriation, but the ED reported that while background checks and credential verifications are done for agency staff, the facility does not provide or require documentation of abuse, neglect, and misappropriation training for agency personnel and continues to use agency staff without such training documentation.
The facility did not maintain a complete infection prevention and control program, with missing documentation for Legionella prevention, outdated infection control policies, and failure to update procedures for communicable diseases and vaccinations. Staff did not consistently implement enhanced barrier precautions for residents with wounds or non-intact skin, as two CNAs provided high-contact care to a resident on EBP without PPE, and another resident with a reopened wound was not placed on EBP until several days after the wound was identified.
Three residents were prescribed psychotropic medications, including those with black box warnings, without proper documentation of informed consent from themselves or their legal representatives. Required consent forms were either missing, incomplete, or not properly signed and dated, despite facility policy mandating thorough review and documentation of consent for such medications.
Two residents who were hospitalized did not receive the required written transfer and bed-hold notices, nor were their transfers properly reported to the Ombudsman. One resident, who was cognitively intact, was transferred to the ED without written notification, and staff later admitted to shredding the forms. Another resident with moderate cognitive impairment and a POA for healthcare was transferred for cellulitis, but only received verbal notification, with no written notice provided to the resident or representative. The Ombudsman was not notified in either case, and staff interviews revealed inconsistent practices regarding these regulatory requirements.
A resident with multiple chronic conditions and moderately impaired cognition experienced a reopened chronic wound and was placed on enhanced barrier precautions (EBP). Despite new physician orders for wound care and the initiation of EBP, the care plan was not updated to reflect these changes. Staff confirmed the care plan omissions, and the DON acknowledged that necessary interventions and precautions were not added.
Two residents with severe cognitive impairment and high fall risk experienced multiple falls, but their care plans were not updated with new interventions after each incident as required by facility policy. Additionally, a fall mat intervention was not consistently implemented for one resident, with the mat found under the bed instead of beside it. Staff and medical record reviews confirmed that the process for revising care plans post-fall was not followed.
A resident with COPD and chronic respiratory failure, who required continuous oxygen therapy, was observed with a nasal cannula connected to a portable oxygen tank that was not turned on, resulting in an oxygen saturation of 69%. An LPN confirmed the oxygen should have been set at 2 LPM, and after adjustment, the resident's saturation improved to 97%. The facility lacked an oxygen use policy, and staff did not follow the physician's order for continuous oxygen.
The QAA committee did not consistently include the required members, as the DON/IP was absent from two quarterly meetings, resulting in incomplete committee attendance for quality assessment and assurance activities affecting all residents.
A resident with severe cognitive impairment and a history of infections was observed with their catheter drainage bag in direct contact with a floor mat without a protective barrier. Staff interviews confirmed that the facility's practice was to use covers for catheter bags and to keep them off the floor, which was not followed in this instance.
Failure to Report Allegation of Sexual Abuse to Law Enforcement and State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse to local law enforcement and the State Agency as required by its own policy and by section 1150B of the Act. On 4/15/26, a resident with Lewy Body dementia, psychotic/mood disturbance, depression, severe cognitive impairment (BIMS score 6/15), and an activated POA for healthcare told a CNA during morning cares that they had been raped two days earlier. The CNA ensured the resident’s safety and immediately reported the allegation to an LPN and the DON. Later that morning, the resident again stated they had been raped in the presence of the Activities Director and the DON, and the DON acknowledged hearing these statements in a common area. Despite multiple staff being aware of the allegation, no report was made to local law enforcement or the State Agency. The LPN stated they did not take further action because the DON was already aware. The DON confirmed that the incident was not reported externally, even though the facility’s abuse investigation policy requires all allegations of abuse to be sent immediately to the Division of Quality Assurance and indicates that investigations are to include notification to outside authorities such as law enforcement and APS as applicable. The Executive Director reported being informed of the allegation during a behavior meeting later that morning and verified that the allegation was not reported to law enforcement or the State Agency due to concerns about the resident’s potential psychological distress from an investigation, police involvement, or hospitalization, even though the facility typically reports such allegations.
Failure to Thoroughly Investigate Resident’s Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly and accurately investigate an allegation of sexual abuse made by one resident. On 4/15/26, during morning cares at approximately 7:00 AM, the resident told a CNA that the resident had been raped two days earlier. The CNA ensured the resident was safe and immediately reported the allegation to an LPN and the DON. Later that morning, the resident again stated that the resident had been raped to the Activities Director and the DON while in a common area. The resident’s medical record showed diagnoses including Lewy Body dementia with psychotic/mood disturbance and depression, and a BIMS score of 6/15 indicating severely impaired cognition, with an activated POA for healthcare. Despite the facility’s written policy requiring a thorough investigation of abuse allegations, including collecting and preserving physical evidence, interviewing the alleged victim and witnesses, interviewing other residents and staff, and involving regulatory authorities such as law enforcement, these steps were not carried out. The DON confirmed hearing the resident’s rape allegation and reported completing a skin assessment and updating the care plan, but did not recall staff interviews being conducted and verified that law enforcement was not notified. The Executive Director confirmed that no additional staff or resident interviews were completed and that a sexual assault exam was not offered to the resident or the resident’s POA. The Executive Director also confirmed that staff education related to reporting and investigating requirements was not completed, demonstrating that the facility did not follow its own policy for a thorough and accurate investigation of the abuse allegation.
Failure to Prevent Resident-to-Resident Physical Abuse Involving Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect three residents from physical abuse by another resident. One resident (R1), admitted with dementia and anxiety disorder and assessed with a BIMS score of 3/15 indicating severely impaired cognition, physically assaulted two other cognitively impaired residents. Another resident (R2), admitted with Alzheimer's disease and dementia and assessed with a BIMS score of 0/15, was observed during a facility-reported incident on 12/4/25 at approximately 5:30 PM in an argument with R1 at the end of the hallway. Staff, including an LPN, witnessed R1 holding and aggressively squeezing R2's right wrist. R2 was noted to have bruising on the right hand and wrist, and R1 later was documented to have a reddish-purple bruise and a skin tear on the top of the left hand. Both residents were unable to provide an account of the incident, and R1 believed R2 was trespassing in R1's room. In a separate facility-reported incident on 12/9/25, R1 targeted another resident, R4, who was also admitted with dementia and anxiety disorder and had a BIMS score of 0/15, indicating severely impaired cognition. Staff observed R1 stick a leg out in front of R4's wheelchair as if to trip R4, then become aggressive, grab R4's right hand/wrist, and refuse to let go. R4 called out, stating that R1 was hurting them, and was later documented to have two bruises on the right hand. An RN progress note and staff interviews confirmed that R1 attempted to trip R4 and grabbed R4's right hand, causing pain and visible bruising. These incidents demonstrate that the facility did not prevent resident-to-resident physical abuse involving vulnerable, cognitively impaired residents.
Failure to Prevent Misappropriation of Resident Property by Agency CNA
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when an agency CNA took cash and gift cards from the resident’s belongings. The resident, who had type 2 diabetes and rheumatoid arthritis and was cognitively intact with a BIMS score of 15/15, reported with their responsible party that $276.00, a McDonald’s gift card, and a Starbucks gift card were missing from the resident’s walker. The incident was reported to staff in the morning, and the missing items were identified by the resident and the resident’s child as having been stored on the walker. The facility’s abuse, neglect, and misappropriation policy requires that residents not be subjected to abuse or misappropriation by anyone, and that staff receive training in interventions, reporting, detection, and what constitutes abuse, neglect, and misappropriation, as well as implementation of procedures to identify, correct, and intervene in situations likely to result in misappropriation. Despite this, the Executive Director stated that while the facility conducts background checks, TB tests, and verifies licenses, COVID-19 vaccination, and CPR certification for agency staff, it does not require or provide abuse, neglect, and misappropriation training for agency staff and relies on the staffing agency to ensure such training. The Executive Director also stated the facility continues to use agency staff without requiring documentation of abuse, neglect, and misappropriation training from the agency. An agency CNA admitted to taking the resident’s money and gift cards, and later returned the gift cards and an amount of cash that did not match the amount reported missing.
Inadequate Infection Control Program and Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program, as evidenced by incomplete policies, lack of required documentation, and improper implementation of enhanced barrier precautions (EBP). The facility's Legionella Policy and Procedure for Water Management did not include a detailed flow diagram of the water system, and the Maintenance Director was unable to provide such a diagram or specific corrective actions for situations when Legionella control measures were not met. Additionally, infection control policies were not reviewed or updated annually, and several policies lacked current information, such as updates on pneumococcal and influenza vaccines, procedures for staff who refuse vaccinations, and a comprehensive list of communicable diseases that must be reported to the health department. Staff failed to implement EBP as required for residents with wounds or non-intact skin. One resident, who had a percutaneous endoscopic gastrostomy (PEG) tube removed and was on EBP due to open skin, was observed receiving high-contact care, including linen changes and shaving, from two CNAs who did not wear personal protective equipment (PPE). The CNAs were unclear about when PPE was required, and one CNA stated that PPE was only necessary when in direct contact with the wound dressing, despite the resident being on EBP for a wound. The Director of Nursing confirmed that PPE should have been used during these high-risk tasks. Another resident with a chronic wound that reopened was not placed on EBP until three days after the wound was identified. During this period, staff were observed providing care without PPE, and there was no EBP signage or PPE cart outside the resident's room. The Director of Nursing verified that EBP should have been implemented immediately when the wound reopened, but this did not occur until several days later.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents or their legal representatives were fully informed and provided written consent prior to the administration of psychotropic medications. For one resident with intact cognition and a diagnosis of anxiety and muscle spasms, there was no documented consent for the prescribed diazepam, a medication with a black box warning. For another resident with moderate cognitive impairment and an activated Power of Attorney for Healthcare (POAHC), consent forms for lorazepam, bupropion, and duloxetine were not properly initialed, dated, or signed by the POAHC after the expiration of verbal consent. A third resident, who had severe cognitive impairment and an activated POAHC, was prescribed olanzapine, also with a black box warning, without a completed informed consent form in the medical record. The facility's policy required that residents or their responsible parties be informed of the reasons for psychotropic medication orders, possible side effects, and alternative methods, and that written consent be obtained and documented. Staff interviews confirmed that the required consent forms were either missing, incomplete, or not properly reviewed and signed, resulting in a lack of documented informed consent for the use of psychotropic medications for these residents.
Failure to Provide Required Transfer, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide required written notifications and documentation regarding transfer, bed-hold policies, and appeal rights for two residents who were hospitalized. One resident, who was cognitively intact and responsible for their own healthcare decisions, was transferred to the emergency department due to a toe injury but did not receive a written transfer or bed hold notice. The facility also did not notify the Ombudsman of this transfer. Staff interviews revealed confusion about when to complete and provide these notices, with one nurse admitting to shredding the forms under the mistaken belief that they were only necessary for hospital admissions, not transfers. Another resident, who had moderate cognitive impairment and an activated Power of Attorney for Healthcare, was transferred to the hospital for cellulitis. The medical record indicated only verbal notification was provided, with no evidence that a written transfer or bed hold notice was given or mailed to the resident or their representative. Additionally, the Ombudsman was not notified of this transfer. Staff interviews confirmed inconsistent practices regarding the provision and documentation of these notices, and the facility's discharge notifications to the Ombudsman did not include residents transferred with a bed hold, contrary to regulatory requirements.
Failure to Revise Care Plan After Wound Reopened and Enhanced Barrier Precautions Initiated
Penalty
Summary
The facility failed to revise the care plan for a resident after a chronic wound reopened and after the resident was placed on enhanced barrier precautions (EBP). The resident, who had diagnoses including chronic diastolic heart failure, metabolic encephalopathy, and chronic kidney disease, was admitted with moderately impaired cognition and had an activated Power of Attorney for Healthcare. The care plan, dated prior to the wound reopening, did not reflect the presence of the wound or the implementation of EBP. Progress notes documented that the wound reopened and that new physician orders were obtained for wound care, but these changes were not incorporated into the resident's care plan. Staff interviews confirmed that the care plan was not updated to include the reopened wound or the initiation of EBP. The Director of Nursing acknowledged that wound interventions and precautions should have been added to the care plan when the wound reopened. Additionally, the Nursing Home Administrator indicated that the facility did not have a care plan policy in place.
Failure to Update Fall Interventions and Implement Safety Measures
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision or implement appropriate interventions to prevent accidents for two residents with severe cognitive impairment and high fall risk. Both residents had multiple falls within a short period, and their care plans were not updated with new interventions following each incident, despite facility policy requiring such updates. For one resident, the care plan included the use of a fall mat when in bed, but this intervention was not consistently implemented, as the fall mat was observed under the bed rather than beside it on at least one occasion. Medical records and staff interviews confirmed that after each fall, no new interventions were added to the care plans of either resident, and the process for updating care plans post-fall was not followed. Both residents had significant cognitive deficits and mobility issues, further increasing their risk for falls. The facility's own fall policy required that a new intervention be added to the care plan after each fall, but this was not done, and required safety equipment was not always in place as specified.
Failure to Provide Ordered Continuous Oxygen Therapy
Penalty
Summary
A resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia, who had severe cognitive impairment and an activated Power of Attorney, was admitted with a physician's order for continuous oxygen at no more than 3 liters per minute (LPM) to maintain oxygen saturation at 90% or above. During observation, the resident was seen in a wheelchair with a nasal cannula connected to a portable oxygen tank that was not turned on, and the tank was set at 0. Upon verification by an LPN, it was confirmed that the oxygen should have been set at 2 LPM continuously, and that CNAs were responsible for turning on the oxygen tank unless an adjustment was needed. The resident's oxygen saturation was measured at 69% before the oxygen was turned on and increased to 97% after the oxygen was set to 2 LPM. Further review revealed that the facility did not have an oxygen use policy in place, as confirmed by the Director of Nursing. The resident's medical record included orders for continuous oxygen and regular checks and changes of oxygen tubing, but these were not followed at the time of the surveyor's observation. The failure to ensure the resident's oxygen was administered as ordered constituted a deficiency in providing necessary respiratory care and services.
QAA Committee Lacked Required Members at Quarterly Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee included the minimum required members and met at least quarterly as required. Review of QAA committee meeting sign-in sheets for the past four quarters showed that the committee met on four occasions; however, the Director of Nursing (DON), who also served as the Infection Preventionist (IP), was absent from two of these meetings. This absence was confirmed by both documentation and staff interview with the Nursing Home Administrator (NHA), who verified that the DON/IP did not attend the meetings in question. As a result, the QAA committee did not meet with all required members for two of the four reviewed quarters, affecting the oversight of quality assessment and assurance processes for all 31 residents in the facility.
Inappropriate Care for Resident with Indwelling Catheter
Penalty
Summary
The facility did not provide appropriate care and services for a resident with an indwelling catheter. On 4/10/24, a surveyor observed the resident's catheter drainage bag in direct contact with a floor mat without a barrier to prevent infection. The facility's policy on the nursing care of an indwelling urinary catheter did not include a process to prevent catheter drainage bag exposure to potentially infectious settings. The resident, who had severe cognitive impairment and a history of infections, was found asleep in bed with the catheter bag resting on the floor mat next to the foot of the bed. Interviews with staff revealed that the facility's practice was to use a cover for catheter drainage bags and to ensure that uncovered bags were not in contact with the floor. A CNA and an RN both confirmed that catheter bags should not be on the floor and should contain a cloth cover for infection control and dignity. The Nursing Home Administrator also stated that staff were expected to keep catheter bags covered and off the floor.
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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 Seymour
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Anna John Resident Centered Care Community | 7.9 mi | — | 0 | 0 |
| Woodside Lutheran Home | 12.5 mi | — | 13 | 0 |
| Ccc Of West Green Bay | 12.7 mi | — | 0 | 0 |
| Rennes Health And Rehab Center-de Pere | 12.9 mi | — | 9 | 0 |
| Green Bay Health Services | 12.9 mi | — | 0 | 0 |
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