A list of the most recent deficiencies for Good Samaritan Society - St James. 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 each resident receives an accurate assessment. | Health | 2023-08-31 | 2023-09-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-08-31 | 2023-09-29 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-08-31 | 2023-09-29 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-08-31 | 2023-09-29 | 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 | 2023-08-31 | 2023-09-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-31 | 2023-09-29 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-08-31 | 2023-09-29 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-08-31 | 2023-09-29 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-31 | 2023-09-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-31 | 2023-09-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-11 | 2023-05-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-11 | 2023-05-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-27 | 2023-04-07 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-02-27 | 2023-04-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-08 | 2023-04-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-08 | 2023-04-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-09 | 2022-11-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-20 | 2022-11-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-20 | 2022-11-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-20 | 2022-11-18 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-10-20 | 2022-11-18 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-03 | 2022-04-02 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-03-03 | 2022-04-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-03 | 2022-04-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-03 | 2022-04-02 | 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 | 2022-03-03 | 2022-04-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-03 | 2022-04-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-03 | 2022-04-02 | 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 | 2022-03-03 | 2022-04-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-03 | 2022-04-02 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-03-01 | 2022-04-02 | N |
| Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | Fire Safety | 2022-03-01 | 2022-04-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-23 | 2021-12-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-15 | 2021-11-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-31 | 2021-10-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-21 | 2021-05-05 | Y |
| 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 | 2019-12-18 | 2020-01-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-18 | 2020-01-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-12-18 | 2020-01-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-18 | 2020-01-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-18 | 2020-01-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-17 | 2019-12-19 | N |
