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Deficiency Records for Good Shepherd Lutheran Home
View the most recent health deficiencies and inspection results for Good Shepherd Lutheran Home. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Good Shepherd Lutheran Home. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2026-03-03 | 2026-03-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2026-03-03 | 2026-03-25 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2026-03-03 | 2026-03-25 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-05-01 | 2025-05-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2025-05-01 | 2025-05-22 | 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 | 2025-05-01 | 2025-05-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-05-01 | 2025-05-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-05-01 | 2025-05-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-05-01 | 2025-05-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-05-01 | 2025-05-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2025-05-01 | 2025-05-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-05-01 | 2025-05-22 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-05-01 | 2025-05-22 | N |
| Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Health | 2025-05-01 | 2025-05-22 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2025-05-01 | 2025-05-22 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2025-05-01 | 2025-05-22 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2025-05-01 | 2025-05-22 | 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 | 2025-05-01 | 2025-05-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-05-01 | 2025-05-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2025-05-01 | 2025-05-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-05-01 | 2025-05-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-05-01 | 2025-05-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-05-01 | 2025-05-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-05-01 | 2025-05-22 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2025-05-01 | 2025-05-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-04-23 | 2024-05-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-04-23 | 2024-05-15 | 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 | 2024-04-23 | 2024-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-23 | 2024-05-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-04-23 | 2024-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-23 | 2024-05-15 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-04-23 | 2024-05-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-04-23 | 2024-05-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-04-23 | 2024-05-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-04-23 | 2024-05-15 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-04-23 | 2024-05-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-23 | 2024-05-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-04 | 2024-04-11 | Y |
| Keep all essential equipment working safely. | Health | 2023-05-03 | 2023-06-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-03 | 2023-06-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-03 | 2023-06-16 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-05-03 | 2023-06-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-03 | 2023-06-16 | 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 | 2023-05-03 | 2023-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-03 | 2023-06-16 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-05-03 | 2023-06-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-03 | 2023-06-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-03 | 2023-06-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-03 | 2023-06-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-03 | 2023-06-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-03 | 2023-06-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-03 | 2023-06-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-03 | 2023-06-16 | N |