Deficiency Records for Good Samaritan Society Las Cruces Village
Updated as of March 01, 2024
A list of the most recent deficiencies for Good Samaritan Society Las Cruces 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-01 | 2023-03-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-01 | 2023-03-27 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-02-01 | 2023-03-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-01 | 2023-03-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-01 | 2023-03-27 | 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 | 2023-02-01 | 2023-03-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-01 | 2023-03-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-01 | 2023-03-27 | 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 | 2023-02-01 | 2023-03-27 | 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 | 2023-02-01 | 2023-03-27 | 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 | 2023-02-01 | 2023-03-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-02-01 | 2023-03-27 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-02-01 | 2023-03-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-01 | 2023-03-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-01 | 2023-03-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-01 | 2023-03-27 | Y |
| Assess the resident when there is a significant change in condition | Health | 2023-02-01 | 2023-03-27 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-02-01 | 2023-03-27 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-17 | 2023-03-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-17 | 2023-03-27 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-01-17 | 2023-03-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-22 | 2022-05-02 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-03-22 | 2022-05-02 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-03-22 | 2022-05-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-22 | 2022-05-02 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-03-22 | 2022-05-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-22 | 2022-05-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-22 | 2022-05-02 | 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 | 2022-03-22 | 2022-05-02 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-03-22 | 2022-05-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-22 | 2022-05-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-22 | 2022-05-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-22 | 2022-05-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-22 | 2022-05-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-22 | 2022-05-02 | 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 | 2022-03-22 | 2022-05-02 | 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 | 2022-03-22 | 2022-05-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-22 | 2022-05-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-22 | 2022-05-02 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-03-22 | 2022-05-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-03-15 | 2022-05-02 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2022-03-15 | 2022-05-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-20 | 2022-01-25 | Y |
| 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 | 2021-12-20 | 2022-01-25 | Y |
| 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 | 2021-12-20 | 2022-01-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-20 | 2022-01-25 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-09-21 | 2021-10-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-21 | 2021-10-31 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-24 | 2021-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-24 | 2021-05-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-03-24 | 2021-05-15 | 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 | 2021-03-31 | 2021-05-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-03-31 | 2021-05-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-03-31 | 2021-05-14 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-03-31 | 2021-05-14 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-03-31 | 2021-05-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-31 | 2021-05-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-31 | 2021-05-14 | 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 | 2021-03-31 | 2021-05-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-03-31 | 2021-05-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-31 | 2021-05-14 | Y |
| Implement a program that monitors antibiotic use. | Health | 2021-03-31 | 2021-05-14 | Y |
