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Inspection visit

Fire Safety inspection

Good Shepherd Lutheran HomeCMS #28514811 citations on this visit
11 citations recorded

Citations

11 citations recorded*CMS

This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0041GeneralS&S Fpotential for harm

    Implement emergency and standby power systems.

  • 0211GeneralS&S Epotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0222GeneralS&S Epotential for harm

    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.

  • 0321GeneralS&S Fpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0324GeneralS&S Fpotential for harm

    Provide properly protected cooking facilities.

  • 0351GeneralS&S Epotential for harm

    Install an approved automatic sprinkler system.

  • 0511GeneralS&S Fpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0712GeneralS&S Fpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0918GeneralS&S Fpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0920GeneralS&S Fpotential for harm

    Ensure proper usage of power strips and extension cords.

  • 0922GeneralS&S Epotential for harm

    Meet requirements for the use and maintenance of medical gas equipment.

FAQ · About this visit

Common questions about this visit

What happened during the May 1, 2025 survey of Good Shepherd Lutheran Home?

This was a inspection survey of Good Shepherd Lutheran Home on May 1, 2025. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Good Shepherd Lutheran Home on May 1, 2025?

Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Implement emergency and standby power systems."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.