Deficiency Records for Good Samaritan Society - St Luke's Village
Updated as of April 01, 2024
A list of the most recent deficiencies for Good Samaritan Society - St Luke's Village. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-05 | 2024-03-15 | N |
| 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 | 2024-02-05 | 2024-03-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-02-05 | 2024-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-05 | 2024-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-05 | 2024-03-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-30 | 2024-03-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-30 | 2024-03-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-30 | 2024-03-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-01-30 | 2024-03-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-19 | 2023-01-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-19 | 2023-01-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-19 | 2023-01-20 | 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 | 2022-12-19 | 2023-01-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-12-19 | 2023-01-20 | 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 | 2022-12-19 | 2023-01-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-19 | 2023-01-20 | 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 | 2022-12-14 | 2023-01-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-14 | 2023-01-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-29 | 2022-12-21 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-11-29 | 2022-12-21 | 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 | 2022-11-29 | 2022-12-21 | Y |
| 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 | 2022-11-29 | 2022-12-21 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-29 | 2022-12-21 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-11-29 | 2022-12-21 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-28 | 2021-08-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-28 | 2021-08-31 | 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 | 2021-07-28 | 2021-08-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-28 | 2021-08-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-28 | 2021-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-28 | 2021-08-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-28 | 2021-08-31 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-22 | 2021-08-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-22 | 2021-08-31 | N |
