Deficiency Records for Good Shepherd Health and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Good Shepherd Health and Rehabilitation. 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 implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-17 | 2023-11-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-17 | 2023-11-18 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-11-17 | 2023-11-18 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-11-17 | 2023-11-18 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-11-17 | 2023-11-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-20 | 2023-06-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-20 | 2023-06-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-20 | 2023-04-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-08 | 2021-07-13 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-06-08 | 2021-07-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-08 | 2021-07-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-31 | 2019-11-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-31 | 2019-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-31 | 2019-11-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-09 | 2018-11-06 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-10-11 | 2018-10-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-11 | 2018-10-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-11 | 2018-10-18 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-08-24 | 2017-08-30 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-08-24 | 2017-08-30 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-08-24 | 2017-08-30 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-08-24 | 2017-08-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-08-24 | 2017-08-28 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-24 | 2017-08-28 | N |
