Deficiency Records for The Shepherd's Center
Updated as of August 01, 2019
This is not the most recent data for The Shepherd's Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-04-12 | 2019-05-28 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-04-12 | 2019-05-28 | N |
| Develop a communication plan. | Fire Safety | 2019-04-12 | 2019-05-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-04-12 | 2019-05-28 | 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 | 2018-06-19 | 2018-06-29 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2018-06-19 | 2018-06-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-06-19 | 2018-06-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-06-19 | 2018-06-29 | Y |
| Try to resolve each resident's complaints quickly. | Health | 2017-12-01 | 2017-12-29 | Y |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-12-01 | 2017-12-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-12-01 | 2017-12-29 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-08-25 | 2017-09-24 | Y |
| Review or revise the resident's care plan after any major change in physical or mental health. | Health | 2017-08-25 | 2017-09-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-25 | 2017-09-24 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-06-06 | 2017-06-26 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-06-06 | 2017-06-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-06-06 | 2017-06-26 | N |
| Send unopened mail from residents and promptly deliver unopened mail to residents. | Health | 2016-05-25 | 2016-06-24 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2016-05-25 | 2016-06-24 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-05-25 | 2016-06-24 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-05-25 | 2016-06-24 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-05-25 | 2016-06-24 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-05-25 | 2016-06-24 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2016-05-25 | 2016-06-24 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-05-25 | 2016-06-24 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-05-25 | 2016-06-24 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-05-25 | 2016-06-24 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2015-12-14 | 2015-12-28 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-06-06 | Not Fixed | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-06 | Not Fixed | N |
| Assess the resident when there is a significant change in condition | Health | 2019-06-06 | 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 | 2019-06-06 | Not Fixed | 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 | 2019-06-06 | Not Fixed | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-06 | Not Fixed | N |
| 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 | 2019-06-06 | 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 | 2019-06-06 | Not Fixed | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-06-06 | Not Fixed | 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 ne | Health | 2019-06-06 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-06 | Not Fixed | N |
