A list of the most recent deficiencies for Good Samaritan Society Betty Dare. 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? |
|---|---|---|---|---|
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-10 | 2023-12-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-10 | 2023-12-08 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-10-10 | 2023-12-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-10 | 2023-12-08 | 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 | 2023-10-10 | 2023-12-08 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-10-10 | 2023-12-08 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-10-10 | 2023-12-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-10 | 2023-12-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-10 | 2023-12-08 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-10-10 | 2023-12-08 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-10-10 | 2023-12-08 | N |
| Provide activities to meet all resident's needs. | Health | 2023-10-10 | 2023-12-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-10 | 2023-12-08 | 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 | 2023-10-10 | 2023-12-08 | 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 | 2023-10-10 | 2023-12-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-10 | 2023-12-08 | 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 | 2023-10-10 | 2023-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-10 | 2023-12-08 | 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 | 2023-10-06 | 2023-12-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-06 | 2023-12-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-06 | 2023-12-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-06 | 2023-12-08 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-05-12 | 2023-07-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-12 | 2023-07-28 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-05-12 | 2023-07-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-12 | 2023-07-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-12 | 2023-07-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-12 | 2023-07-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-12 | 2023-07-28 | Y |
| 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 | 2022-10-11 | 2022-12-30 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-10-11 | 2022-12-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-11 | 2022-12-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-11 | 2022-12-30 | N |
| Provide activities to meet all resident's needs. | Health | 2022-10-11 | 2022-12-30 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-10-11 | 2022-12-30 | 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 | 2022-10-11 | 2022-12-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-11 | 2022-12-30 | 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 | 2022-10-11 | 2022-12-30 | 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 | 2022-10-11 | 2022-12-30 | 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 | 2022-10-11 | 2022-12-30 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-10-11 | 2022-12-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-10-11 | 2022-12-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-11 | 2022-12-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-14 | 2022-06-25 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-14 | 2022-06-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-14 | 2022-06-17 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-04-14 | 2022-06-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-05 | 2021-12-24 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-10-05 | 2021-12-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-05 | 2021-12-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-05 | 2021-12-24 | N |
| Provide activities to meet all resident's needs. | Health | 2021-10-05 | 2021-12-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-05 | 2021-12-24 | 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 | 2021-10-05 | 2021-12-24 | 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 | 2021-10-05 | 2021-12-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-05 | 2021-12-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-10-05 | 2021-12-24 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-10-05 | 2021-12-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-10-05 | 2021-12-24 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-10-05 | 2021-12-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-05 | 2021-12-24 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-22 | 2021-12-05 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-09-22 | 2021-11-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-22 | 2021-10-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-09-22 | 2021-09-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-02 | 2021-03-27 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-02 | 2021-03-27 | 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 | 2021-03-02 | 2021-03-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-02 | 2021-03-27 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-03-02 | 2021-03-27 | Y |
