A list of the most recent deficiencies for Good Shepherd 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-16 | 2022-06-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-16 | 2022-06-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-16 | 2022-06-09 | 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 | 2022-05-16 | 2022-06-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-16 | 2022-06-09 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-05-16 | 2022-06-09 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-05-16 | 2022-06-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-16 | 2022-06-09 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-16 | 2022-06-09 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-05-16 | 2022-06-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-16 | 2022-06-09 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-05-16 | 2022-06-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-16 | 2022-06-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-16 | 2022-06-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-16 | 2022-06-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-16 | 2022-06-09 | Y |
| 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 | 2022-05-09 | 2022-06-09 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-05-09 | 2022-06-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-09 | 2022-06-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-09 | 2022-06-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-07 | 2021-07-20 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-06-27 | 2019-08-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-27 | 2019-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-27 | 2019-08-16 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-06-27 | 2019-08-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-06-27 | 2019-08-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-27 | 2019-08-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-06-27 | 2019-08-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-25 | 2019-08-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-06-25 | 2019-08-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-25 | 2019-08-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-25 | 2019-08-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-25 | 2019-08-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-06-25 | 2019-08-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-25 | 2019-08-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-25 | 2019-08-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-25 | 2019-08-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-19 | 2018-06-07 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-04-19 | 2018-06-07 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-04-19 | 2018-06-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-19 | 2018-06-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-19 | 2018-06-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-04-19 | 2018-06-07 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-04-17 | 2018-06-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-17 | 2018-06-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-04-17 | 2018-06-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-04-17 | 2018-06-07 | N |
