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Deficiency Records for Good Samaritan Society - Colonial Villa
A list of the most recent deficiencies for Good Samaritan Society - Colonial Villa. 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 - Colonial Villa. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-23 | 2024-09-04 | 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 | 2024-07-23 | 2024-09-04 | 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 | 2024-07-23 | 2024-09-04 | 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 | 2024-07-23 | 2024-09-04 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2024-07-18 | 2024-09-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-18 | 2024-09-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-18 | 2024-09-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-18 | 2024-09-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-18 | 2024-09-04 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-07-18 | 2024-09-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-07-18 | 2024-09-04 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-07-18 | 2024-09-04 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-21 | 2023-07-28 | 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 | 2023-06-21 | 2023-07-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-21 | 2023-07-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-04-13 | 2022-05-20 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-04-13 | 2022-05-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-04-13 | 2022-05-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-13 | 2022-05-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-13 | 2022-05-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-13 | 2022-05-20 | 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 | 2022-04-13 | 2022-05-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-13 | 2022-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-13 | 2022-05-20 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-13 | 2022-05-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-04-07 | 2022-05-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-07 | 2022-05-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-07 | 2022-05-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-07 | 2022-05-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-07 | 2022-05-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-07 | 2022-05-20 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-06 | 2022-02-18 | Y |
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