A list of the most recent deficiencies for Golden Good Shepherd 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-11 | 2023-12-04 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-09-11 | 2023-10-06 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-09-11 | 2023-09-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-09-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-09-07 | 2023-09-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-11 | 2023-09-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-11 | 2023-09-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-07 | 2023-09-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-11 | 2023-09-11 | 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 | 2023-09-07 | 2023-09-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-31 | 2022-10-27 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-08-31 | 2022-10-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-31 | 2022-10-15 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-08-31 | 2022-10-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-31 | 2022-10-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-31 | 2022-10-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-31 | 2022-10-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-31 | 2022-10-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-31 | 2022-10-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-31 | 2022-10-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-18 | 2022-09-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-18 | 2022-09-07 | N |
| Respond appropriately to all alleged violations. | Health | 2022-08-18 | 2022-09-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-18 | 2022-09-07 | 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 | 2022-08-31 | 2022-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-31 | 2022-08-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-11-03 | 2021-12-18 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-03 | 2021-11-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-03 | 2021-11-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-03 | 2021-11-15 | N |
