A list of the most recent deficiencies for Good Shepherd-Fairview Home Inc. 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 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 | 2024-01-19 | 2024-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-19 | 2024-03-15 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-01-19 | 2024-03-15 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-01-19 | 2024-03-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-19 | 2024-03-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-19 | 2024-03-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-19 | 2024-03-15 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2024-01-19 | 2024-03-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-01-19 | 2024-03-15 | N |
| Respond appropriately to all alleged violations. | Health | 2023-07-24 | 2023-08-04 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-09 | 2021-11-08 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2021-09-09 | 2021-11-08 | N |
| Keep all essential equipment working safely. | Health | 2021-09-09 | 2021-11-08 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-09-09 | 2021-11-08 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-09-09 | 2021-11-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-02 | 2019-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-02 | 2019-06-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-05-01 | 2019-06-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-05-01 | 2019-06-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-05-01 | 2019-06-30 | N |
