Deficiency Records for Good Samaritan Society - Ellis
Updated as of June 01, 2021
This is not the most recent data for Good Samaritan Society - Ellis. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-02-05 | 2019-03-04 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-02-05 | 2019-03-04 | N |
| Develop a communication plan. | Fire Safety | 2019-02-05 | 2019-03-04 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-02-05 | 2019-03-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-05 | 2019-03-04 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-02-05 | 2019-03-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-02-05 | 2019-03-04 | 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 | 2019-02-05 | 2019-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-05 | 2019-03-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-02-05 | 2019-03-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-05 | 2019-03-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-05 | 2019-03-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-05 | 2019-03-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-05 | 2019-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-05 | 2019-03-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-05 | 2019-03-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-01-09 | 2019-01-31 | N |
| Respond appropriately to all alleged violations. | Health | 2019-01-09 | 2019-01-31 | 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 | 2019-01-09 | 2019-01-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-09 | 2019-01-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-09 | 2019-01-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-01-09 | 2019-01-31 | 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 | 2019-01-09 | 2019-01-31 | 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 | 2019-01-09 | 2019-01-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-01-09 | 2019-01-31 | 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 | 2019-01-09 | 2019-01-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-01-09 | 2019-01-11 | N |
| Meet other general requirements. | Fire Safety | 2018-06-13 | 2018-06-19 | Y |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2018-06-13 | 2018-06-19 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-06-13 | 2018-06-19 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-13 | 2018-06-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-08-17 | 2017-09-13 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-08-17 | 2017-09-13 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-08-17 | 2017-09-13 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-08-17 | 2017-09-13 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-17 | 2017-09-13 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-08-17 | 2017-09-13 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-17 | 2017-09-13 | N |
| Have a correctly designed non-healthcare occupancy area in a health care facility. | Fire Safety | 2017-04-04 | 2017-05-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-04-04 | 2017-05-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-04-04 | 2017-05-11 | 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 | 2017-04-04 | 2017-05-11 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2017-04-04 | 2017-05-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2017-04-04 | 2017-05-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-04-04 | 2017-05-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-04-04 | 2017-05-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-04-04 | 2017-05-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-04-04 | 2017-05-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-04-04 | 2017-05-11 | N |
