Deficiency Records for Good Samaritan Society Las Cruces Village
Updated as of November 01, 2021
This is not the most recent data for Good Samaritan Society Las Cruces Village. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2020-07-27 | 2020-08-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-24 | 2019-12-20 | 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 | 2019-10-24 | 2019-12-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-24 | 2019-12-20 | 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 | 2019-10-24 | 2019-12-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-24 | 2019-12-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-24 | 2019-12-20 | 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 | 2019-10-24 | 2019-12-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-24 | 2019-12-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-24 | 2019-12-20 | 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 | 2019-10-24 | 2019-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-24 | 2019-12-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-24 | 2019-12-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-10-24 | 2019-12-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-10-24 | 2019-12-20 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-24 | 2019-12-20 | 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 | 2019-10-24 | 2019-12-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-28 | 2018-10-12 | 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 | 2018-08-28 | 2018-10-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-08-28 | 2018-10-12 | 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 | 2018-08-28 | 2018-10-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-08-28 | 2018-10-12 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-08-28 | 2018-10-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-08-28 | 2018-10-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-08-28 | 2018-10-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-28 | 2018-10-12 | 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 | 2018-08-28 | 2018-10-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-28 | 2018-10-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-28 | 2018-10-12 | 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 | 2018-08-28 | 2018-10-12 | 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 | 2018-08-28 | 2018-10-12 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2018-08-28 | 2018-10-12 | 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 | 2018-08-28 | 2018-10-12 | 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 | 2018-08-28 | 2018-10-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-08-28 | 2018-10-12 | 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 | 2018-08-28 | 2018-10-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-28 | 2018-10-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-08-28 | 2018-10-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-08-28 | 2018-10-12 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-08-22 | 2018-10-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-08-22 | 2018-10-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-22 | 2018-10-12 | N |
