Deficiency Records for Good Samaritan Society - Ellis

(Home page)

Updated as of March 01, 2024

A list of the most recent deficiencies for Good Samaritan Society - Ellis. 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?
Have horizontal exits used in accordance with safety requirements. Fire Safety 2022-10-12 2022-10-14 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2022-10-12 2022-10-14 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-10-12 2022-10-14 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-10-12 2022-10-14 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2022-10-12 2022-10-14 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-10-12 2022-10-14 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-10-12 2022-10-14 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-08-29 2022-09-30 Y
Give residents a notice of rights, rules, services and charges. Health 2022-08-29 2022-09-30 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-08-29 2022-09-30 Y
Respond appropriately to all alleged violations. Health 2022-08-29 2022-09-30 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-08-29 2022-09-30 Y
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2022-08-29 2022-09-30 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-08-29 2022-09-30 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2022-08-29 2022-09-30 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-08-29 2022-09-30 Y
Provide enough food/fluids to maintain a resident's health. Health 2022-08-29 2022-09-30 Y
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2022-08-29 2022-09-30 Y
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2022-08-29 2022-09-30 Y
Ensure that residents are free from significant medication errors. Health 2022-08-29 2022-09-30 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-08-29 2022-09-30 Y
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2021-08-25 2021-09-23 N
Provide properly protected cooking facilities. Fire Safety 2021-08-25 2021-09-23 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-08-25 2021-09-23 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-08-25 2021-09-23 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2021-08-25 2021-09-23 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2021-08-25 2021-09-23 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-08-25 2021-09-23 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-08-25 2021-09-23 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-07-19 2021-07-30 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 2021-07-19 2021-07-30 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-07-19 2021-07-30 N
Provide enough food/fluids to maintain a resident's health. Health 2021-07-19 2021-07-30 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2021-07-19 2021-07-30 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 2021-07-19 2021-07-30 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 2021-07-19 2021-07-30 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 2021-07-19 2021-07-30 N
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Health 2021-07-19 2021-07-30 N
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2021-07-19 2021-07-30 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2019-12-02 2020-03-06 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2019-12-02 2020-03-06 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 2019-12-02 2020-03-06 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2019-12-02 2020-03-06 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2019-12-02 2020-03-06 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2019-12-02 2020-03-06 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-12-02 2020-03-06 N
Ensure proper usage of power strips and extension cords. Fire Safety 2019-12-02 2020-03-06 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 2019-12-19 2020-01-22 N
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Health 2019-12-19 2020-01-22 N