Deficiency Records for Good Samaritan Society - Colonial Villa
Updated as of April 01, 2024
A list of the most recent deficiencies for Good Samaritan Society - Colonial Villa. 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 that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-21 | 2023-07-28 | 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 | 2023-06-21 | 2023-07-28 | N |
Provide and implement an infection prevention and control program. | Health | 2023-06-21 | 2023-07-28 | N |
Implement emergency and standby power systems. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
Have restrictions on the use of flammable curtains. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
Have power receptacles that are properly grounded. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-20 | 2023-07-28 | N |
Assess the resident when there is a significant change in condition | Health | 2022-04-13 | 2022-05-20 | N |
Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-04-13 | 2022-05-20 | 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 | 2022-04-13 | 2022-05-20 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-13 | 2022-05-20 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-13 | 2022-05-20 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-13 | 2022-05-20 | 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 | 2022-04-13 | 2022-05-20 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-13 | 2022-05-20 | N |
Provide and implement an infection prevention and control program. | Health | 2022-04-13 | 2022-05-20 | N |
Ensure staff are vaccinated for COVID-19 | Health | 2022-04-13 | 2022-05-20 | 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 | 2022-04-07 | 2022-05-20 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-07 | 2022-05-20 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-07 | 2022-05-20 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-07 | 2022-05-20 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-07 | 2022-05-20 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-07 | 2022-05-20 | N |
Perform COVID19 testing on residents and staff. | Health | 2022-01-06 | 2022-02-18 | Y |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-09-22 | 2020-10-09 | N |
Meet other general requirements. | Fire Safety | 2020-09-17 | 2020-10-09 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2020-09-17 | 2020-10-09 | N |
Meet requirements for the use of electrical equipment. | Fire Safety | 2020-09-17 | 2020-10-09 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-09-17 | 2020-10-09 | N |