Deficiency Records for Good Samaritan Society - Saint Ansgar
Updated as of April 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 |