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Deficiency Records for Good Shepherd Lutheran Home
A list of the most recent deficiencies for Good Shepherd Lutheran Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Good Shepherd Lutheran Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-24 | 2024-05-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-24 | 2024-03-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-25 | 2024-02-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-25 | 2024-02-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-24 | 2024-02-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-24 | 2024-02-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-24 | 2024-02-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-24 | 2024-02-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-24 | 2024-02-09 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-10-12 | 2022-11-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-12 | 2022-11-24 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-10-10 | 2022-11-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-10 | 2022-11-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-10-12 | 2022-11-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-10 | 2022-11-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-10 | 2022-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-10 | 2022-11-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-10 | 2022-11-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-10 | 2022-11-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-10 | 2022-11-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-10 | 2022-11-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-10-10 | 2022-10-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-10 | 2022-10-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-10 | 2022-10-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-21 | 2022-08-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-21 | 2022-08-01 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-08-15 | 2019-09-24 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-15 | 2019-09-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-15 | 2019-09-24 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-08-16 | 2019-09-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-16 | 2019-09-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-08-15 | 2019-09-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-15 | 2019-09-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-16 | 2019-09-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-16 | 2019-09-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-16 | 2019-08-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-15 | 2019-08-23 | N |
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