Deficiency Records for Good Samaritan Society - Saint Ansgar

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Updated as of March 01, 2024

A list of the most recent deficiencies for Good Samaritan Society - Saint Ansgar. 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?
Assess the resident when there is a significant change in condition Health 2024-01-10 2024-02-08 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 2024-01-10 2024-02-08 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-01-10 2024-02-08 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 2024-01-10 2024-02-08 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2024-01-17 2024-01-24 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2024-01-17 2024-01-24 N
Establish policies and procedures for volunteers. Fire Safety 2024-01-17 2024-01-24 N
Develop a communication plan. Fire Safety 2024-01-17 2024-01-24 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2024-01-17 2024-01-24 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2024-01-17 2024-01-24 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-01-17 2024-01-24 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2024-01-17 2024-01-24 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2024-01-17 2024-01-24 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2024-01-17 2024-01-24 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2024-01-17 2024-01-24 N
Ensure each resident receives an accurate assessment. Health 2022-09-09 2022-10-07 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 2022-09-09 2022-10-07 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-09-09 2022-10-07 N
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. Fire Safety 2022-09-15 2022-09-16 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-09-15 2022-09-15 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 2021-04-08 2021-05-08 N
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. Health 2021-04-08 2021-05-08 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 2021-04-08 2021-05-08 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-04-08 2021-05-08 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2021-04-08 2021-05-08 N
Provide and implement an infection prevention and control program. Health 2021-04-08 2021-05-08 N
Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Health 2021-04-08 2021-05-08 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-04-08 2021-05-08 Y
Provide primary/alternate means for communication. Fire Safety 2021-04-06 2021-05-06 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2021-04-06 2021-05-06 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2021-04-06 2021-05-06 N
Have proper medical gas storage and administration areas. Fire Safety 2021-04-06 2021-05-06 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2021-04-06 2021-04-15 N