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 |