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Deficiency Records for Good Shepherd Care Center
A list of the most recent deficiencies for Good Shepherd Care Center. 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 Care Center. 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? |
|---|---|---|---|---|
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-02-16 | 2024-04-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-16 | 2024-04-01 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-02-16 | 2024-04-01 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-02-16 | 2024-04-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-16 | 2024-04-01 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-02-16 | 2024-04-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-02-16 | 2024-04-01 | N |
| Use approved construction type or materials. | Fire Safety | 2024-02-16 | 2024-04-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-16 | 2024-04-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-16 | 2024-04-01 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-02-16 | 2024-04-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-02-16 | 2024-04-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-16 | 2024-04-01 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-02-16 | 2024-04-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-16 | 2024-04-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-04 | 2022-12-30 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-11-04 | 2022-12-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-04 | 2022-12-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-11-04 | 2022-12-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-04 | 2022-12-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-04 | 2022-12-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-04 | 2022-12-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-04 | 2022-12-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-04 | 2022-12-19 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-11-04 | 2022-12-01 | N |
| Post nurse staffing information every day. | Health | 2022-11-04 | 2022-11-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-11-04 | 2022-11-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-04 | 2022-11-23 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-09-27 | 2019-11-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-27 | 2019-11-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-27 | 2019-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-27 | 2019-11-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
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