Good Shepherd Village

Name: Good Shepherd Village
Address: 422 NORTH BURNETT ROAD, Springfield, OH, 45503, US
Telephone: 9373221911

422 North Burnett Road, Springfield, OH 45503 · Clark County · 81 certified beds · avg 58 residents/day · certified since Apr 6, 2002

SFF Candidate

Part of chain: AOM HEALTHCARE (20 facilities, chain avg rating 2.7★)

1/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.76

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Jan 23, 2020 · F-0686

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Mar 20, 2020 (Deficient, Provider has date of correction)

All citations in the current public record (60)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jun 30, 2026	F · Potential for harm, facility-wide	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Jun 30, 2026	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Jun 30, 2026	D · Potential for harm, one-off	The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint
Jun 30, 2026	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
Jun 30, 2026	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jun 30, 2026	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jun 30, 2026	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Jun 30, 2026	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint
Jun 30, 2026	D · Potential for harm, one-off	The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. · from a complaint
May 1, 2025	F · Potential for harm, facility-wide	The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint
May 1, 2025	F · Potential for harm, facility-wide	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
May 1, 2025	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 1, 2025	E · Potential for harm, repeated	The facility did not honor residents' right to manage their own money and financial affairs.
May 1, 2025	E · Potential for harm, repeated	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
May 1, 2025	E · Potential for harm, repeated	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
May 1, 2025	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
May 1, 2025	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
May 1, 2025	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
May 1, 2025	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
May 1, 2025	E · Potential for harm, repeated	The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint
May 1, 2025	E · Potential for harm, repeated	The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
May 1, 2025	E · Potential for harm, repeated	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
May 1, 2025	D · Potential for harm, one-off	The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
May 1, 2025	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
May 1, 2025	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
May 1, 2025	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
May 1, 2025	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
May 1, 2025	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
May 1, 2025	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
May 1, 2025	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
May 1, 2025	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint
May 1, 2025	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
May 1, 2025	D · Potential for harm, one-off	The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · from a complaint
May 1, 2025	D · Potential for harm, one-off	The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign.
May 1, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 1, 2025	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
May 1, 2025	C · Minimal risk, facility-wide	The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately.
Mar 20, 2025	E · Potential for harm, repeated	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Mar 20, 2025	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Mar 20, 2025	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Mar 20, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Apr 10, 2024	D · Potential for harm, one-off	The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
Apr 10, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Nov 27, 2023	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Nov 27, 2023	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint
Nov 27, 2023	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Oct 17, 2023	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Sep 7, 2023	D · Potential for harm, one-off	The facility did not allow a resident's chosen representative — often a family member or someone with power of attorney — to exercise the resident's rights on their behalf. When a resident can't speak for themselves, their representative steps into that role. · from a complaint
Dec 19, 2022	E · Potential for harm, repeated	The facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died.
Dec 19, 2022	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Dec 19, 2022	D · Potential for harm, one-off	The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents.
Jan 23, 2020	▲ G · Actual harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Jan 23, 2020	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jan 23, 2020	E · Potential for harm, repeated	The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Jan 23, 2020	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jan 23, 2020	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Jan 23, 2020	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Jan 23, 2020	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jan 23, 2020	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jan 23, 2020	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (3 → 28).

Year	Citations	Serious (G–L)	Worst severity that year
2020	9	1	G ▲
2022	3	0	E
2023	5	0	E
2024	2	0	D
2025	32	0	F
2026	9	0	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

0 fines totaling $0, plus 1 Medicare payment denial period.

Date	Type	Amount / length
May 1, 2025	Payment Denial	20 days from Jun 13, 2025

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Ohio avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.76	3.45	3.95	top 22% in Ohio; bottom 49% in the U.S.
Registered Nurse hours	0.65	0.60	0.69	top 31% in Ohio; top 42% in the U.S.
Weekend total nurse staffing	3.24	3.07	3.50	top 28% in Ohio; bottom 44% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.25	0.42	0.48	bottom 18% in Ohio; bottom 21% in the U.S.
Total nursing staff turnover (%)	48.6	48.7	45.8	bottom 50% in Ohio; bottom 40% in the U.S.
RN turnover (%)	66.7	43.9	42.9	bottom 18% in Ohio; bottom 15% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.29, RN 0.57, weekend 2.84. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Goldstein, Jeffery	Individual	5% or Greater Indirect Ownership Interest	—	02/01/2022
LT Investor LLC	Organization	5% or Greater Indirect Ownership Interest	—	02/01/2022
Oelbaum, Yitzchok	Individual	5% or Greater Indirect Ownership Interest	—	02/01/2022
Sherman, Lea	Individual	5% or Greater Indirect Ownership Interest	—	02/01/2022
Springfield Nursing LLC	Organization	5% or Greater Direct Ownership Interest	100%	02/01/2022
Tratner, Leah	Individual	5% or Greater Indirect Ownership Interest	—	02/01/2022
Yamo Equities Limited Liability Company	Organization	5% or Greater Indirect Ownership Interest	—	02/01/2022
Goldstein, Jeffery	Individual	W-2 Managing Employee	NOT APPLICABLE	02/01/2022
Goldstein, Jeffery	Individual	Corporate Officer	NOT APPLICABLE	02/01/2022

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"Could I join residents for a meal to see the food quality and temperature for myself?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
"Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Springfield Nursing & Independent Living	1.9 mi	Springfield, OH	★☆☆☆☆	1/5
Allen View Healthcare Center	2.3 mi	Springfield, OH	★☆☆☆☆	1/5
Northwood Skilled Nursing and Rehabilitation	2.7 mi	Springfield, OH	★★☆☆☆	2/5
Aventura at Oakwood Village	2.7 mi	Springfield, OH	★☆☆☆☆	2/5
Villa Springfield Rehabilitation and Healthcare Ce	3.0 mi	Springfield, OH	★★☆☆☆	2/5
Arbors at Springfield	3.2 mi	Springfield, OH	★★☆☆☆	2/5
Wooded Glen	3.7 mi	Springfield, OH	★★★★★	5/5
Forest Glen Rehabilitation and Healthcare Center	3.8 mi	Springfield, OH	★★★★☆	4/5
Southbrook Healthcare Center	4.0 mi	Springfield, OH	★★★☆☆	2/5
Springfield Masonic Community	4.8 mi	Springfield, OH	★★★★☆	3/5
Friends Extended Care Center	11.2 mi	Yellow Springs, OH	★★★★☆	4/5
Dayspring of Miami Valley HLTH Care Center & Rehab	11.5 mi	Fairborn, OH	★★★★★	5/5

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 366236.

The Care File

Visit checklist — Good Shepherd Village

422 North Burnett Road, Springfield, OH 45503 · 9373221911

Health inspection rating 1/5 · CMS overall 2/5 · SFF Candidate· Fines (3y): $0

Most serious findings on record:

▲ Jan 23, 2020 (F-0686, Actual harm, one-off): The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Questions for the administrator:

☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "Could I join residents for a meal to see the food quality and temperature for myself?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
☐ "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 366236 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)