Good Shepherd Services Ltd

Inspection findings

1. Apr 21, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Apr 22, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Apr 22, 2026 · CMS health inspection

2. Mar 20, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Apr 20, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0602 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from the wrongful use of the resident's belongings or money.

     Corrected Apr 20, 2026 · CMS health inspection

3. May 29, 2025 Fire Safety · 11 findings
   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Jun 29, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected Jun 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Jun 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Jun 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jun 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jun 29, 2025 · CMS health inspection

   • Not serious Scope/severity C

     F0868 Administration Deficiencies

     Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

     Corrected Jun 29, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 29, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0132 Construction Deficiencies

     Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

     Corrected Jun 29, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 29, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jun 29, 2025 · CMS fire safety

4. Apr 11, 2024 Fire Safety · 5 findings
   • Not serious Scope/severity F

     E0035 Emergency Preparedness Deficiencies

     Provide family notifications of emergency plan.

     Corrected May 11, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected May 11, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected May 11, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected May 11, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 11, 2024 · CMS fire safety

5. Apr 19, 2023 Health · 4 findings
   • Not serious Scope/severity D

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected May 5, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 8, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0300 Egress Deficiencies

     Meet other general requirements that are deficient.

     Corrected May 4, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected May 2, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• GILLIAM, DAWN — adp of the snf, NOT APPLICABLE, since 11/01/2006
• GILLIAM, DAWN — corporate director, NOT APPLICABLE, since 03/16/2025
• HARTIG, DONALD — adp of the snf, NOT APPLICABLE, since 04/16/2025
• HARTIG, DONALD — operational/managerial control, NOT APPLICABLE, since 11/22/2021
• KATCH, JEAN — operational/managerial control, NOT APPLICABLE, since 12/31/2024
• KATCH, JEAN — managing control - governing body, NOT APPLICABLE, since 12/31/2024
• KATCH, JEAN — corporate director, NOT APPLICABLE, since 12/31/2024
• MCCLONE, KARLA — managing control - governing body, NOT APPLICABLE, since 04/01/2024
• MCCLONE, KARLA — corporate director, NOT APPLICABLE, since 04/01/2024
• MCCLONE, KARLA — operational/managerial control, NOT APPLICABLE, since 04/01/2024
• PIEHL, CAYLA — adp of the snf, NOT APPLICABLE, since 01/29/2024
• PIEHL, CAYLA — operational/managerial control, NOT APPLICABLE, since 01/29/2024
• RICKERT, LISA — corporate officer, NOT APPLICABLE, since 04/01/2022
• RICKERT, LISA — managing control - governing body, NOT APPLICABLE, since 04/01/2022
• RICKERT, LISA — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• RICKERT, LISA — corporate director, NOT APPLICABLE, since 04/01/2022
• SCHROEDER, TODD — managing control - governing body, NOT APPLICABLE, since 12/31/2024
• SCHROEDER, TODD — corporate director, NOT APPLICABLE, since 12/31/2024
• SCHROEDER, TODD — corporate officer, NOT APPLICABLE, since 12/31/2024
• SCHROEDER, TODD — operational/managerial control, NOT APPLICABLE, since 12/31/2024
• WALTERS, JOEL — managing control - governing body, NOT APPLICABLE, since 04/01/2022
• WALTERS, JOEL — corporate director, NOT APPLICABLE, since 04/01/2022
• WALTERS, JOEL — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• ZAHN, JOYCE — managing control - governing body, NOT APPLICABLE, since 12/31/2024
• ZAHN, JOYCE — operational/managerial control, NOT APPLICABLE, since 12/31/2024
• ZAHN, JOYCE — corporate director, NOT APPLICABLE, since 12/31/2024
• WIPFLI LLP — operational/managerial control, NOT APPLICABLE, since 01/13/1987
• WIPFLI LLP — adp of the snf, NOT APPLICABLE, since 04/24/2025