A list of the most recent deficiencies for Good Shepherd Care 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-04 | 2022-12-30 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-11-04 | 2022-12-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-04 | 2022-12-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-11-04 | 2022-12-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-04 | 2022-12-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-04 | 2022-12-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-04 | 2022-12-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-04 | 2022-12-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-04 | 2022-12-19 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-11-04 | 2022-12-01 | N |
| Post nurse staffing information every day. | Health | 2022-11-04 | 2022-11-30 | 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 | 2022-11-04 | 2022-11-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-04 | 2022-11-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-20 | 2021-07-20 | Y |
| Assess the resident when there is a significant change in condition | Health | 2019-09-27 | 2019-11-01 | 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 | 2019-09-27 | 2019-11-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-27 | 2019-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-27 | 2019-11-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-27 | 2019-11-01 | 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 | 2019-09-27 | 2019-11-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-27 | 2019-11-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-27 | 2019-11-01 | 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 | 2018-12-07 | 2019-01-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-12-07 | 2019-01-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-07 | 2019-01-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-12-07 | 2019-01-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-07 | 2019-01-02 | N |
