A list of the most recent deficiencies for Good Shepherd Lutheran Home. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-23 | 2023-05-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-23 | 2023-05-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-23 | 2023-05-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-23 | 2023-05-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-23 | 2023-05-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-21 | 2023-05-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-21 | 2023-05-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-21 | 2023-05-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-21 | 2023-05-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-19 | 2023-02-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-17 | 2022-11-21 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-04 | 2021-12-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-04 | 2021-12-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-04 | 2021-12-15 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-02 | 2021-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-02 | 2021-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-02 | 2021-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-04 | 2021-12-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-15 | 2021-05-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-15 | 2021-05-17 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-16 | 2019-10-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-15 | 2019-09-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-15 | 2019-09-24 | 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 | 2019-08-15 | 2019-09-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-15 | 2019-09-24 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-08-15 | 2019-09-12 | N |
