Care Citations

THE SHEPHERD'S CENTER

101 CEDAR RIDGE DRIVE, CIMARRON, KS, 67835 · 6208553498

What CMS has flagged

  • CMS status on record: SFF Candidate.

On the CMS record

Overall rating (CMS)
2 / 5
Health inspection rating
1 / 5
Staffing rating
5 / 5
Certified beds
28
Ownership type
Non profit - Corporation

Inspection findings on record (26)

Quoted exactly as CMS published them. We do not rewrite findings.

— Nursing and Physician Services Deficiencies

Tag 0730 · scope/severity F · potential for more than minimal harm

Observe each nurse aide's job performance and give regular training.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0801 · scope/severity F · potential for more than minimal harm

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Administration Deficiencies

Tag 0838 · scope/severity F · potential for more than minimal harm

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Recorded as corrected on .

— Administration Deficiencies

Tag 0867 · scope/severity F · potential for more than minimal harm

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity F · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0881 · scope/severity F · potential for more than minimal harm

Implement a program that monitors antibiotic use.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0636 · scope/severity E · potential for more than minimal harm

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0628 · scope/severity D · potential for more than minimal harm

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity D · potential for more than minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0655 · scope/severity D · potential for more than minimal harm

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity D · potential for more than minimal harm

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity L · immediate jeopardy

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity L · immediate jeopardy

Respond appropriately to all alleged violations.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0602 · scope/severity J · immediate jeopardy

Protect each resident from the wrongful use of the resident's belongings or money.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Administration Deficiencies

Tag 0851 · scope/severity F · potential for more than minimal harm

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Recorded as corrected on .

— Administration Deficiencies

Tag 0867 · scope/severity F · potential for more than minimal harm

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity F · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0655 · scope/severity E · potential for more than minimal harm

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0679 · scope/severity E · potential for more than minimal harm

Provide activities to meet all resident's needs.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity D · potential for more than minimal harm

Provide safe and appropriate respiratory care for a resident when needed.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity D · potential for more than minimal harm

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0947 · scope/severity D · potential for more than minimal harm

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 175570