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Deficiency Records for Good Shepherd Village
A list of the most recent deficiencies for Good Shepherd Village. 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 Village. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-10 | 2024-04-30 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-04-10 | 2024-04-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-10 | 2024-04-12 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-10 | 2024-02-16 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-01-10 | 2024-02-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-27 | 2023-11-29 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-27 | 2023-11-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-27 | 2023-11-29 | Y |
| 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 | 2023-10-17 | 2023-10-18 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-09-07 | 2023-10-18 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-07-31 | 2023-10-18 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-31 | 2023-10-18 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-31 | 2023-10-18 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-31 | 2023-10-18 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-31 | 2023-10-18 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-31 | 2023-10-18 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-31 | 2023-10-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-30 | 2023-06-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-30 | 2023-06-20 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-30 | 2023-06-20 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-05-30 | 2023-06-20 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-30 | 2023-06-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-30 | 2023-06-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-30 | 2023-06-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-08 | 2023-06-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-08 | 2023-06-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-05 | 2023-06-20 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-04-05 | 2023-06-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-05 | 2023-06-20 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-11 | 2023-06-20 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-11 | 2023-06-20 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-13 | 2023-02-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-12-13 | 2023-02-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-13 | 2023-02-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-12-13 | 2023-02-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-13 | 2023-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-13 | 2023-02-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-13 | 2023-02-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-13 | 2023-02-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-13 | 2023-02-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-13 | 2023-02-21 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-12-19 | 2023-01-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-19 | 2023-01-16 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-12-19 | 2023-01-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-23 | 2020-03-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-23 | 2020-03-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-23 | 2020-03-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-23 | 2020-03-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-23 | 2020-03-20 | 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 | 2020-01-23 | 2020-03-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-01-23 | 2020-03-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-23 | 2020-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-23 | 2020-03-20 | 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 | 2020-01-22 | 2020-03-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-22 | 2020-03-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-22 | 2020-03-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-22 | 2020-03-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-22 | 2020-03-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-22 | 2020-03-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-22 | 2020-03-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-06 | 2019-01-11 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-12-06 | 2019-01-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-12-06 | 2019-01-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-12-06 | 2019-01-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-12-06 | 2019-01-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-12-06 | 2019-01-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-06 | 2019-01-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-12-06 | 2019-01-11 | 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 | 2018-12-06 | 2019-01-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-06 | 2019-01-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-12-06 | 2019-01-11 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2018-12-06 | 2019-01-11 | 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 | 2018-12-06 | 2019-01-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-06 | 2019-01-11 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-12-06 | 2019-01-11 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2018-12-04 | 2019-01-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-04 | 2019-01-11 | N |
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