Deficiency Records for Good Samaritan Society - Ellis
Updated as of October 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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-25 | 2021-09-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-25 | 2021-09-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-25 | 2021-09-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-25 | 2021-09-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-25 | 2021-09-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-25 | 2021-09-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-25 | 2021-09-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-25 | 2021-09-24 | 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 |
| 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 |
