Deficiency Records for Good Samaritan Health and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Good Samaritan Health and Rehab Center. 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? |
|---|---|---|---|---|
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-24 | 2023-10-10 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-24 | 2023-10-10 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-24 | 2023-10-10 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-07-24 | 2023-08-28 | N |
| Develop a communication plan. | Fire Safety | 2023-07-24 | 2023-08-28 | N |
| Establish methods for sharing information. | Fire Safety | 2023-07-24 | 2023-08-28 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-07-24 | 2023-08-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-24 | 2023-08-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-24 | 2023-08-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-02 | 2023-08-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-02 | 2023-08-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-08-02 | 2023-08-23 | 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 | 2023-08-02 | 2023-08-23 | 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 | 2023-08-02 | 2023-08-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-02 | 2023-08-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-02 | 2023-08-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-02 | 2023-08-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-02 | 2023-08-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-02 | 2023-08-23 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-08-02 | 2023-08-23 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-08-02 | 2023-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-02 | 2023-08-23 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-08-02 | 2023-08-23 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-07-24 | 2023-08-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-07-24 | 2023-08-23 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-07-24 | 2023-08-23 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-07-24 | 2023-08-23 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-07-24 | 2023-08-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-07-24 | 2023-08-23 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-07-24 | 2023-08-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-07-24 | 2023-08-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-07-24 | 2023-08-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-24 | 2023-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-24 | 2023-08-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-24 | 2023-08-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-24 | 2023-08-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-22 | 2022-12-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-10 | 2022-11-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-03 | 2022-09-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-03 | 2022-09-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-03 | 2022-09-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-03 | 2022-09-01 | 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 | 2022-08-03 | 2022-09-01 | Y |
| Post nurse staffing information every day. | Health | 2022-08-03 | 2022-09-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-03 | 2022-09-01 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-29 | 2019-06-07 | 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 | 2019-05-02 | 2019-05-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-05-02 | 2019-05-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-29 | 2019-05-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-04-29 | 2019-05-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-29 | 2019-05-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-29 | 2019-05-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-29 | 2019-04-30 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-04-29 | 2019-04-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-04-29 | 2019-04-29 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-29 | 2019-04-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-29 | 2019-04-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-29 | 2019-04-29 | 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 | 2018-04-18 | 2018-05-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-04-18 | 2018-05-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-04-18 | 2018-05-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-18 | 2018-05-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-04-18 | 2018-05-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-18 | 2018-05-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-04-18 | 2018-05-04 | 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 | 2018-04-18 | 2018-05-04 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-04-18 | 2018-05-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-16 | 2018-04-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-16 | 2018-04-16 | N |
