A list of the most recent deficiencies for The Shepherd's 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-14 | 2024-03-13 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-02-14 | 2024-03-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-14 | 2024-03-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-14 | 2024-03-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-14 | 2024-03-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-14 | 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 | 2024-02-14 | 2024-03-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-14 | 2024-03-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-14 | 2024-03-13 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-03-30 | 2022-05-12 | N |
| 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 | 2022-03-30 | 2022-05-12 | 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 | 2022-03-30 | 2022-05-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-30 | 2022-05-12 | 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 | 2022-03-30 | 2022-05-12 | N |
| Post nurse staffing information every day. | Health | 2022-03-30 | 2022-05-12 | 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 | 2022-03-30 | 2022-05-12 | 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 | 2022-03-30 | 2022-05-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-30 | 2022-05-12 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-30 | 2022-05-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-01-11 | 2021-02-10 | 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 | 2020-10-29 | 2020-12-08 | 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 | Not Fixed | 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 | Not Fixed | N |
| Provide activities to meet all resident's needs. | Health | 2024-02-08 | Not Fixed | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-08 | Not Fixed | 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 | Not Fixed | 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 | Not Fixed | 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 | Not Fixed | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-08 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-08 | Not Fixed | 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 | Not Fixed | N |
