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Deficiency Records for The Shepherd's Center
View the most recent health deficiencies and inspection results for The Shepherd's Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for The Shepherd's Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2025-11-17 | 2026-03-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-11-17 | 2026-03-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-11-17 | 2026-03-05 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2025-11-17 | 2026-03-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2025-11-17 | 2026-03-02 | 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 | 2025-11-17 | 2026-03-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-11-17 | 2026-03-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-11-17 | 2026-03-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2025-11-17 | 2026-03-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-11-17 | 2026-03-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-11-17 | 2026-03-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-11-17 | 2025-12-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-11-17 | 2025-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-11-17 | 2025-12-10 | 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 | 2025-11-17 | 2025-12-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2025-11-17 | 2025-12-10 | 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 | 2025-11-17 | 2025-12-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-11-17 | 2025-12-10 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Health | 2025-11-17 | 2025-12-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2025-11-17 | 2025-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-11-17 | 2025-12-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2025-11-17 | 2025-12-10 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-11-17 | 2025-12-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2025-11-17 | 2025-12-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-27 | 2024-07-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-06-27 | 2024-07-10 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-06-27 | 2024-07-10 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-08 | 2024-03-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-08 | 2024-03-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-08 | 2024-03-13 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-02-08 | 2024-03-13 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-08 | 2024-03-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-08 | 2024-03-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-08 | 2024-03-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-08 | 2024-03-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-08 | 2024-03-13 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-02-08 | 2024-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-08 | 2024-03-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-08 | 2024-03-01 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-02-08 | 2024-03-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-08 | 2024-03-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-02-08 | 2024-03-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-08 | 2024-03-01 | N |
| Provide activities to meet all resident's needs. | Health | 2024-02-08 | 2024-03-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-08 | 2024-03-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-08 | 2024-03-01 | N |