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Deficiency Records for Good Samaritan Society - Ellis
A list of the most recent deficiencies for Good Samaritan Society - Ellis. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Good Samaritan Society - Ellis. 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? |
|---|---|---|---|---|
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-04-02 | 2024-06-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-04-02 | 2024-04-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-04-02 | 2024-04-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-02 | 2024-04-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-02 | 2024-04-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-02 | 2024-04-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-11 | 2024-04-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-11 | 2024-04-05 | Y |
| 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. | Health | 2024-03-11 | 2024-04-05 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-11 | 2024-04-05 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-03-11 | 2024-04-05 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-03-11 | 2024-04-05 | Y |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2022-10-12 | 2022-10-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-12 | 2022-10-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-12 | 2022-10-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-12 | 2022-10-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-12 | 2022-10-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-12 | 2022-10-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-12 | 2022-10-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-29 | 2022-09-30 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2022-08-29 | 2022-09-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-29 | 2022-09-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-29 | 2022-09-30 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-29 | 2022-09-30 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-08-29 | 2022-09-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-29 | 2022-09-30 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-29 | 2022-09-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-29 | 2022-09-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-29 | 2022-09-30 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-29 | 2022-09-30 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-08-29 | 2022-09-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-29 | 2022-09-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-29 | 2022-09-30 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-25 | 2021-09-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-25 | 2021-09-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-25 | 2021-09-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-25 | 2021-09-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-25 | 2021-09-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-25 | 2021-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-25 | 2021-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-25 | 2021-09-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-19 | 2021-07-30 | 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 | 2021-07-19 | 2021-07-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-19 | 2021-07-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-19 | 2021-07-30 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-07-19 | 2021-07-30 | 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 | 2021-07-19 | 2021-07-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-07-19 | 2021-07-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-19 | 2021-07-30 | N |
| 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. | Health | 2021-07-19 | 2021-07-30 | 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 | 2021-07-19 | 2021-07-30 | N |
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