Deficiency Records for Good Shepherd Home
Updated as of June 01, 2019
This is not the most recent data for Good Shepherd Home. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-01-30 | 2019-03-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-30 | 2019-03-01 | Y |
| 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 |
| 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 |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-05-18 | 2017-06-16 | 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 | 2017-02-16 | 2017-04-05 | 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 | 2017-02-16 | 2017-04-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-02-16 | 2017-04-05 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2017-02-16 | 2017-04-05 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2017-02-16 | 2017-04-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-02-16 | 2017-04-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-02-15 | 2017-04-05 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-02-15 | 2017-04-05 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-02-15 | 2017-04-05 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-02-15 | 2017-04-05 | N |
| Make sure that special or therapeutic diets are ordered by the attending doctor. | Health | 2017-02-15 | 2017-04-05 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-02-15 | 2017-04-05 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-09-18 | 2016-10-21 | Y |
| A two-hour-resistant firewall separation. | Fire Safety | 2015-12-03 | 2016-01-29 | N |
| Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2015-12-03 | 2016-01-29 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2015-12-03 | 2016-01-29 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2015-12-03 | 2016-01-29 | N |
| Horizontal exits. | Fire Safety | 2015-12-03 | 2016-01-29 | N |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2015-12-03 | 2016-01-29 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2015-12-03 | 2016-01-29 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2015-12-03 | 2016-01-29 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-12-03 | 2016-01-29 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2015-12-03 | 2016-01-29 | N |
