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 | 2022-10-12 | 2022-11-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-12 | 2022-11-24 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-10-10 | 2022-11-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-10 | 2022-11-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-10-12 | 2022-11-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-10 | 2022-11-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-10 | 2022-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-10 | 2022-11-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-10 | 2022-11-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-10 | 2022-11-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-10 | 2022-11-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-10 | 2022-11-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-10-10 | 2022-10-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-10 | 2022-10-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-10 | 2022-10-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-21 | 2022-08-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-21 | 2022-08-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-07 | 2021-06-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-07 | 2021-06-25 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-08-15 | 2019-09-24 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-15 | 2019-09-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-15 | 2019-09-24 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-08-16 | 2019-09-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-16 | 2019-09-20 | 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 | 2019-09-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-15 | 2019-09-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-16 | 2019-09-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-16 | 2019-09-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-16 | 2019-08-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-15 | 2019-08-23 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-09-27 | 2018-11-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-09-27 | 2018-11-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-27 | 2018-11-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-27 | 2018-11-06 | 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 | 2018-09-27 | 2018-11-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-09-27 | 2018-11-06 | N |
| Provide or arrange emergency care by a doctor 24 hours a day. | Health | 2018-09-27 | 2018-11-06 | 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 | 2018-09-27 | 2018-11-06 | N |
| Provide or obtain dental services for each resident. | Health | 2018-09-27 | 2018-11-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-27 | 2018-11-06 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2018-09-27 | 2018-11-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-09-24 | 2018-11-06 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-09-27 | 2018-10-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-09-27 | 2018-10-25 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-09-24 | 2018-10-25 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-09-27 | 2018-10-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-09-27 | 2018-10-01 | N |
