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Health Inspection

Good Shepherd Lutheran Home

April 17, 2025 · Sauk Rapids, MN · 1115 4th Avenue North
Citations 1
CMS Rating 5/5
Beds 146
Provider ID 245269
Healthcare Facility
Good Shepherd Lutheran Home
Sauk Rapids, MN  ·  View full profile →
Inspection Summary

Good Shepherd Lutheran Home in SAUK RAPIDS, MN — inspection on April 17, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF761

During interview on 4/15/25 at 9:25 a.m., LPN-B confirmed R80 was on EBP for a pressure ulcer. LPN-B confirmed she had received education on EBP and should be wearing PPE whenever providing close contact cares. LPN-B confirmed she should have been wearing a gown.

On 4/15/25 at 9:48 a.m., physical therapy assistant (PTA)-F was observed assisting R80 with walking in her room and transferring to her bed. PTA-F was observed assisting R80 adjust the covers on her bed to cover R80's lower body.

During interview on 4/15/25 at 9:51 a.m., PTA-F stated she had received training on EBP and R80 was on EBP. PTA-F stated PPE should have been worn whenever assisting with personal cares, such as dressing or toileting.

During interview on 4/16/25 at 8:22 a.m., clinical manager (CM)-A confirmed R80 was on EBP and staff should wear PPE whenever providing close contact cares, such as transferring, toileting and repositioning. CM-A confirmed staff should have been wearing a gown and gloves while clipping toenails, assisting with physical therapy, and adjusting covers on the bed.

During interview on 4/16/25 at 12:59 p.m., infection control prevention nurse (IP)-G stated all staff are trained on EBP and the facility follows center for disease (CDC) guideline for precautions. IP-G confirmed gown and gloves should have been worn when clipping toenails and providing therapy assistance. IP-G confirmed all departments including therapy was trained on EBP.

During interview on 4/16/25 at 1:16 p.m., director of nursing (DON) stated PPE should be worn any time a staff person is completing hands on care for a resident on EBP.

The DON stated this was important to protect all residents and staff.

Facility infection control and prevention manual dated October 2024, included EBP involved gown and glove use during high-contact resident care activities.

245269

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAUK RAPIDS, MN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Good Shepherd Lutheran Home or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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