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Deficiency Records for Good Samaritan Nursing Home Operator, LLC
A list of the most recent deficiencies for Good Samaritan Nursing Home Operator, LLC. 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 Nursing Home Operator, LLC. 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-07-12 | 2021-09-24 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-07-12 | 2021-09-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-12 | 2021-09-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-12 | 2021-09-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-12 | 2021-09-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-15 | 2021-08-16 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-07-15 | 2021-08-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-15 | 2021-08-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-15 | 2021-08-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-15 | 2021-08-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-04 | 2018-10-22 | N |
| Meet other general requirements. | Fire Safety | 2018-09-04 | 2018-10-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-09-04 | 2018-10-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-04 | 2018-10-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-09-04 | 2018-10-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-04 | 2018-10-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-04 | 2018-10-15 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-08-14 | 2018-09-27 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-08-14 | 2018-09-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-14 | 2018-09-27 | N |
| 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 | 2018-08-14 | 2018-09-27 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-08-14 | 2018-09-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-14 | 2018-09-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-08-14 | 2018-09-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-14 | 2018-09-27 | 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 | 2018-08-14 | 2018-09-27 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-08-14 | 2018-09-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-14 | 2018-09-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-14 | 2018-09-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-08-14 | 2018-09-27 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-08-14 | 2018-09-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-08-14 | 2018-09-27 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-08-14 | 2018-09-27 | 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 | 2018-08-14 | 2018-09-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-14 | 2018-09-27 | 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 | 2018-08-14 | 2018-09-27 | N |
| Provide or obtain dental services for each resident. | Health | 2018-08-14 | 2018-09-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-14 | 2018-09-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-08-14 | 2018-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-14 | 2018-09-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-06-05 | 2017-07-26 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2017-06-05 | 2017-07-26 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2017-06-05 | 2017-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-05 | 2017-07-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-06-05 | 2017-07-26 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2017-06-05 | 2017-07-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-06-05 | 2017-07-26 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2017-06-05 | 2017-07-26 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2017-06-05 | 2017-07-26 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2017-06-05 | 2017-07-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-06-05 | 2017-07-26 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-04-21 | 2017-06-02 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-04-21 | 2017-06-02 | 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 | 2017-04-21 | 2017-06-02 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-04-21 | 2017-06-02 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-21 | 2017-06-02 | N |
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