THE SHEPHERD'S CENTER

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Kansas are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

Long-Term Stay Preventive Actions

Long-Term Stay Deficiencies

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 09/28/2010.

Administration

Keep Accurate and Appropriate Medical Records. Inspection Date: 06/18/2009 Correction Date: 07/18/2009

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 09/28/2010 Correction Date: 10/30/2010
Have a Program to Keep Infection from Spreading. Inspection Date: 09/28/2010 Correction Date: 10/30/2010

Pharmacy Service

Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly. Inspection Date: 06/18/2009 Correction Date: 07/18/2009
1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects. Inspection Date: 09/28/2010 Correction Date: 10/30/2010
Properly Mark Drugs and Other Similar Products. Inspection Date: 09/28/2010 Correction Date: 10/30/2010

Quality Care

Give Professional Services That Meet a Professional Standard of Quality. Inspection Date: 06/19/2008 Correction Date: 07/18/2008
Make Sure That Residents Who Cannot Care for Themselves Receive Help with Eating/Drinking, Grooming and Hygiene. Inspection Date: 06/19/2008 Correction Date: 07/18/2008
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores. Inspection Date: 06/19/2008 Correction Date: 07/18/2008
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary. Inspection Date: 06/19/2008 Correction Date: 07/18/2008
Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion. Inspection Date: 06/19/2008 Correction Date: 07/18/2008
Make Sure That Each Resident's Nutritional Needs Were Met. Inspection Date: 06/19/2008 Correction Date: 07/18/2008
Properly Care for Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, and Prostheses. Inspection Date: 06/19/2008 Correction Date: 07/18/2008
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary. Inspection Date: 06/18/2009 Correction Date: 07/18/2009
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 09/28/2010 Correction Date: 10/30/2010
Make Sure That Residents Who Cannot Care for Themselves Receive Help with Eating/Drinking, Grooming and Hygiene. Inspection Date: 09/28/2010 Correction Date: 10/30/2010
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores. Inspection Date: 09/28/2010 Correction Date: 10/30/2010
Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion. Inspection Date: 09/28/2010 Correction Date: 10/30/2010
Have Enough Nurses to Care for Every Resident in a Way That Maximizes the Resident's Well Being. Inspection Date: 09/28/2010 Correction Date: 10/30/2010

Resident Assessment

Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations. Inspection Date: 06/18/2009 Correction Date: 07/18/2009
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 06/18/2009 Correction Date: 07/18/2009
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations. Inspection Date: 09/28/2010 Correction Date: 10/30/2010
Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them. Inspection Date: 09/28/2010 Correction Date: 10/30/2010
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 09/28/2010 Correction Date: 10/30/2010
1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan. Inspection Date: 09/28/2010 Correction Date: 10/30/2010

Resident Rights

Immediately Tell the Resident, Doctor, and a Family Member If: the Resident is Injured, There is a Major Change in Resident's Physical/Mental Health, There is a Need to Alter Treatment Significantly, or the Resident Must Be Transferred or Discharged. Inspection Date: 06/19/2008 Correction Date: 07/18/2008
Keep Each Resident's Personal and Medical Records Private and Confidential. Inspection Date: 06/18/2009 Correction Date: 07/18/2009
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Inspection Date: 06/18/2009 Correction Date: 07/18/2009
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Inspection Date: 09/28/2010 Correction Date: 10/30/2010

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that The Shepherd's Center had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 06/08/2010.

Automatic Sprinkler Systems

Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 03/11/2008 Correction Date: 04/10/2008
An Approved Automatic Sprinkler System Connected to the Fire Alarm System. Inspection Date: 06/08/2010 Correction Date: 06/23/2010

Electrical

Properly Installed Electrical Wiring and Equipment. Inspection Date: 06/08/2010 Correction Date: 07/08/2010

Emergency Plans and Fire Drills

Record of Quarterly Fire Drills for Each Shift Under Varying Conditions. Inspection Date: 03/11/2008 Correction Date: 04/10/2008

Fire Alarm Systems

An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems. Inspection Date: 06/08/2010 Correction Date: 07/08/2010
Properly Maintained Smoke Detectors. Inspection Date: 06/08/2010 Correction Date: 07/07/2010

Furnishings and Decorations

Exits That Are Free from Obstructions and Can Be Used at All Times. Inspection Date: 06/08/2010 Correction Date: 07/08/2010

Illumination and Emergency Power

Emergency Lighting That Can Last at Least 1 1/2 Hours. Inspection Date: 03/11/2008 Correction Date: 04/10/2008

Laboratories

Emergency Showers. Inspection Date: 03/11/2008 Correction Date: 04/10/2008

Medical Gases and Anesthetizing Areas

Proper Medical Gas Storage and Administration Areas. Inspection Date: 03/11/2008 Correction Date: 04/10/2008