Deficiency Records for Good Samaritan Society - Ellsworth Village
Updated as of July 01, 2022
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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-09 | 2021-12-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-09 | 2021-12-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-09 | 2021-12-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-09 | 2021-12-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-09 | 2021-12-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-09 | 2021-12-07 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-09-27 | 2021-10-25 | N |
| Post nurse staffing information every day. | Health | 2021-09-27 | 2021-10-25 | 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 | 2021-09-27 | 2021-10-25 | 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 | 2021-09-27 | 2021-10-25 | 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 | 2021-09-27 | 2021-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-27 | 2021-10-25 | N |
| 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 |
