Deficiency Records for Good Samaritan Society - Ellsworth Village
Updated as of September 01, 2021
This is not the most recent data for Good Samaritan Society - Ellsworth Village. For the most recent information, click here.
A list of the most recent deficiencies for Good Samaritan Society - Ellsworth Village. 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 residents are free from significant medication errors. | Health | 2020-03-04 | 2020-03-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-11 | 2020-01-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-11 | 2020-01-10 | 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 | 2019-12-11 | 2020-01-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-11 | 2020-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-11 | 2020-01-10 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-09-04 | 2019-09-23 | 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 | 2019-09-04 | 2019-09-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-04 | 2019-09-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-04 | 2019-09-23 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-09-04 | 2019-09-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-04 | 2019-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-04 | 2019-09-23 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-01-09 | 2019-01-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-01-09 | 2019-01-16 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-01-09 | 2019-01-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-01-09 | 2019-01-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-01-09 | 2019-01-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-01-09 | 2019-01-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-01-09 | 2019-01-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-01-09 | 2019-01-16 | 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 | 2019-01-09 | 2019-01-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-01-09 | 2019-01-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-09 | 2019-01-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-09 | 2019-01-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-01-09 | 2019-01-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-09 | 2019-01-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-01-09 | 2019-01-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-09 | 2019-01-16 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-12-17 | 2019-01-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-12-17 | 2019-01-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-17 | 2019-01-07 | 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 | 2018-12-17 | 2019-01-07 | 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 | 2018-12-17 | 2019-01-07 | 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 | 2018-12-17 | 2019-01-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-12-17 | 2019-01-07 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-08-10 | 2017-09-09 | N |
| Provide housekeeping and maintenance services. | Health | 2017-08-10 | 2017-09-09 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-08-10 | 2017-09-09 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-08-10 | 2017-09-09 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-08-10 | 2017-09-09 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-10 | 2017-09-09 | 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 | 2017-03-10 | 2017-03-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-03-10 | 2017-03-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-03-10 | 2017-03-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-03-10 | 2017-03-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-03-10 | 2017-03-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-03-10 | 2017-03-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-03-10 | 2017-03-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-03-10 | 2017-03-28 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2017-03-10 | 2017-03-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-03-10 | 2017-03-28 | N |
