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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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-04-23 | 2024-05-15 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-04-23 | 2024-05-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-04-21 | 2024-05-15 | 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 | 2024-04-21 | 2024-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-21 | 2024-05-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-04-21 | 2024-05-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-04-21 | 2024-05-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-21 | 2024-05-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-04-21 | 2024-05-15 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-04-21 | 2024-05-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-04-21 | 2024-05-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-04-21 | 2024-05-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-04 | 2024-04-11 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-03 | 2023-06-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-03 | 2023-06-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-03 | 2023-06-16 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-05-03 | 2023-06-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-03 | 2023-06-16 | 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 | 2023-05-03 | 2023-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-03 | 2023-06-16 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-05-03 | 2023-06-16 | Y |
| Keep all essential equipment working safely. | Health | 2023-05-03 | 2023-06-16 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-01 | 2023-06-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-01 | 2023-06-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-01 | 2023-06-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-01 | 2023-06-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-01 | 2023-06-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-01 | 2023-06-16 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-06-28 | 2021-08-12 | N |
| Provide activities to meet all resident's needs. | Health | 2021-06-28 | 2021-08-12 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-06-28 | 2021-08-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-28 | 2021-08-12 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-06-23 | 2021-07-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-23 | 2021-07-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-23 | 2021-07-22 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2021-06-23 | 2021-07-22 | N |
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