Deficiency Records for Good Samaritan Society-Quiburi Mission

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Updated as of January 01, 2023

A list of the most recent deficiencies for Good Samaritan Society-Quiburi Mission. 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?
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-06-24 2021-08-12 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2021-06-24 2021-08-12 N
Ensure each resident receives an accurate assessment. Health 2021-06-24 2021-08-12 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2021-06-24 2021-08-12 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-06-24 2021-08-12 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-06-24 2021-08-12 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-06-24 2021-08-12 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-06-24 2021-08-12 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2021-06-24 2021-08-12 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Health 2021-06-24 2021-08-12 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2021-06-24 2021-08-12 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 2021-06-24 2021-08-12 N
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2021-06-24 2021-08-12 N
Provide properly protected cooking facilities. Fire Safety 2021-06-23 2021-07-26 N
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. Fire Safety 2021-06-23 2021-07-26 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2021-06-23 2021-07-26 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2021-06-23 2021-07-26 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2021-06-23 2021-07-26 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-06-23 2021-07-26 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2019-04-11 2019-06-28 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2019-04-11 2019-06-28 N
Respond appropriately to all alleged violations. Health 2019-04-11 2019-06-28 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2019-04-11 2019-06-28 N
Assist a resident in gaining access to vision and hearing services. Health 2019-04-11 2019-06-28 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 2019-04-11 2019-06-28 N
Provide or obtain dental services for each resident. Health 2019-04-11 2019-06-28 N
Provide properly protected cooking facilities. Fire Safety 2019-04-16 2019-06-18 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2019-04-16 2019-06-18 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2019-04-16 2019-06-18 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2019-04-16 2019-06-18 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2019-04-16 2019-06-18 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-04-16 2019-06-18 N
Ensure proper usage of power strips and extension cords. Fire Safety 2019-04-16 2019-06-18 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2019-04-16 2019-06-18 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2018-02-05 2018-04-30 N
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Health 2018-02-05 2018-04-30 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2018-02-05 2018-04-30 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2018-02-05 2018-04-30 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2018-02-05 2018-04-30 N
Respond appropriately to all alleged violations. Health 2018-02-05 2018-04-30 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2018-02-05 2018-04-30 N
Ensure each resident receives an accurate assessment. Health 2018-02-05 2018-04-30 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2018-02-05 2018-04-30 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 2018-02-05 2018-04-30 N
Post nurse staffing information every day. Health 2018-02-05 2018-04-30 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2018-02-05 2018-04-30 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 2018-02-05 2018-04-30 N
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Health 2018-02-05 2018-04-30 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2018-02-05 2018-04-30 N
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2018-02-05 2018-04-30 N
Provide and implement an infection prevention and control program. Health 2018-02-05 2018-04-30 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2018-02-02 2018-03-16 N
Establish policies and procedures for volunteers. Fire Safety 2018-02-02 2018-03-16 N
Establish roles under a Waiver declared by secretary. Fire Safety 2018-02-02 2018-03-16 N
Have simulated fire drills held at unexpected times. Fire Safety 2018-02-02 2018-03-16 N