Deficiency Records for Good Samaritan Society - Grand Island Village
Updated as of May 01, 2023
This is not the most recent data for Good Samaritan Society - Grand Island Village. For the most recent information, click here.
A list of the most recent deficiencies for Good Samaritan Society - Grand Island 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-12-13 | 2023-01-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-13 | 2023-01-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-13 | 2023-01-05 | 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 | 2022-12-13 | 2023-01-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-13 | 2023-01-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-13 | 2023-01-05 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-12-13 | 2023-01-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-13 | 2023-01-05 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-12-13 | 2023-01-05 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-13 | 2023-01-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-12 | 2022-12-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-12 | 2022-12-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-12-12 | 2022-12-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-12-12 | 2022-12-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-12 | 2022-12-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-12 | 2022-12-30 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-07-21 | 2022-08-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-21 | 2022-08-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-21 | 2022-08-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-08 | 2022-08-05 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-05-18 | 2022-08-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-18 | 2022-08-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-18 | 2022-08-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-18 | 2022-06-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-18 | 2022-06-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-18 | 2022-06-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-18 | 2022-06-14 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-18 | 2022-06-14 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-20 | 2022-02-25 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-08-19 | 2021-09-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-19 | 2021-09-28 | N |
| Post nurse staffing information every day. | Health | 2021-08-19 | 2021-09-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-19 | 2021-09-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-19 | 2021-09-28 | 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 | 2021-08-17 | 2021-09-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-17 | 2021-09-28 | N |
| Respond appropriately to all alleged violations. | Health | 2021-01-27 | 2021-03-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-08-03 | 2020-09-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-08-03 | 2020-09-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-06-18 | 2020-08-07 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-09-26 | 2019-11-18 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-09-26 | 2019-11-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-09-26 | 2019-11-18 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-09-26 | 2019-11-18 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-09-26 | 2019-11-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-09-26 | 2019-11-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-26 | 2019-11-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-26 | 2019-11-18 | 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 | 2019-09-26 | 2019-11-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-26 | 2019-11-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-26 | 2019-11-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-26 | 2019-11-18 | 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 | 2019-09-26 | 2019-11-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-26 | 2019-11-18 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-09-26 | 2019-11-18 | 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 | 2019-09-26 | 2019-11-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-09-26 | 2019-11-18 | N |
| Post nurse staffing information every day. | Health | 2019-09-26 | 2019-11-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-26 | 2019-11-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-26 | 2019-11-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-26 | 2019-11-18 | 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 | 2019-09-26 | 2019-11-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-26 | 2019-11-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-09-26 | 2019-11-18 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-09-26 | 2019-11-18 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-09-26 | 2019-11-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
