Provider Name: GOOD SAMARITAN SOCIETY - SYRACUSE
Address: 1622 WALNUT STREET, SYRACUSE, NE 68446
Phone: (402) 269-2251
County: Otoe (650)
Ownership Type: Non profit - Corporation
Certified Beds: 88
Average Residents Per Day: 44.4 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
First Approved Date: February 1, 1994
Affiliated Entity: EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY (214)
Retirement Community: Y, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 5 ()
Health Inspection Rating: 4 ()
QM Rating: 5 ()
Long Stay QM Rating: 3 ()
Short Stay QM Rating: 5 ()
Staffing Rating: 4 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.36216, LPN Staff Hours Per Day: 0.5018, RN Staff Hours Per Day: 0.5348, Licensed Staff Hours Per Day: 1.0367
Total Nurse Staff Hours Per Day, per resident: 3.39887
Weekend Nurse Staff Hours: 2.67899, Weekend RN Staff Hours: 0.3371
PT Staff Hours Per Day, per resident: 0.0843
Nurse Staff Turnover: 39.5, Nurse Turnover Note:
RN Turnover: 42.9, RN Turnover Note:
Admin Left Number: 0, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 1.8144, Case Mix LPN Hours Per Day: 0.6072, Case Mix RN Hours Per Day: 0.2650
Adjusted Nurse Aide Hours Per Day, per resident: 2.65220, Adjusted LPN Hours Per Day: 0.6099, Adjusted RN Hours Per Day: 0.7604
Total Adjusted Nurse Hours Per Day, per resident: 3.98749
Adjusted Weekend Nurse Hours Per Day, per resident: 3.14294
Health Survey Dates and Scores: Cycle 1: 2024-01-09 (Score: 12), Cycle 2: 2023-01-09 (Score: 36), Cycle 3: 2022-01-06 (Score: 16)
Total Weighted Health Score: 20.667
Reported Incidents: 1, Substantiated Complaints: 0
Infection Control Citations:
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 13000.00, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 1622 WALNUT STREET,SYRACUSE,NE,68446 (40.6675, -96.189)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-09
Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-02-09
Type: Health, Deficiency: Respond appropriately to all alleged violations.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-21
Type: Health, Deficiency: Ensure that residents are fully informed and understand their health status, care and treatments.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Health, Deficiency: Have enough outside ventilation via a window or mechanical ventilation, or both.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Health, Deficiency: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-02-20
Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-02-20
Type: Health, Deficiency: Ensure that residents are free from significant medication errors.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-02-20
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-02-20
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0001, Version: New
Description: Establish an Emergency Preparedness Program (EP).
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-02-09
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-02-18
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-02-18
Type: Fire Safety, Tag: 0355, Version: New
Description: Properly select, install, inspect, or maintain portable fire extinguishes.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-02-18
Type: Fire Safety, Tag: 0363, Version: New
Description: Install corridor and hallway doors that block smoke.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-02-18
Type: Fire Safety, Tag: 0500, Version: New
Description: Meet other general requirements that are deficient.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-02-18
Type: Fire Safety, Tag: 0712, Version: New
Description: Have simulated fire drills held at unexpected times.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-02-18
Type: Fire Safety, Tag: 0920, Version: New
Description: Ensure proper usage of power strips and extension cords.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-02-18
Type: Fire Safety, Tag: 0921, Version: New
Description: Ensure that testing and maintenance of electrical equipment is performed.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-02-18
Type: Fire Safety, Tag: 0922, Version: New
Description: Meet requirements for the use and maintenance of medical gas equipment.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-02-18
Type: Fire Safety, Tag: 0041, Version: New
Description: Implement emergency and standby power systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Fire Safety, Tag: 0345, Version: New
Description: Have approved installation, maintenance and testing program for fire alarm systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Fire Safety, Tag: 0355, Version: New
Description: Properly select, install, inspect, or maintain portable fire extinguishes.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Fire Safety, Tag: 0363, Version: New
Description: Install corridor and hallway doors that block smoke.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Fire Safety, Tag: 0374, Version: New
Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Fire Safety, Tag: 0712, Version: New
Description: Have simulated fire drills held at unexpected times.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Fire Safety, Tag: 0761, Version: New
Description: To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Fire Safety, Tag: 0919, Version: New
Description: Meet requirements for the use of electrical equipment.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Fire Safety, Tag: 0920, Version: New
Description: Ensure proper usage of power strips and extension cords.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-10
Type: Fire Safety, Tag: 0041, Version: New
Description: Implement emergency and standby power systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-01-24
Type: Fire Safety, Tag: 0222, Version: New
Description: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-03-09
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-03-09
Type: Fire Safety, Tag: 0324, Version: New
Description: Provide properly protected cooking facilities.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-01-24
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-01-24
Type: Fire Safety, Tag: 0374, Version: New
Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-01-24
Type: Fire Safety, Tag: 0761, Version: New
Description: To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-01-24
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-01-24
Type: Fire Safety, Tag: 0922, Version: New
Description: Meet requirements for the use and maintenance of medical gas equipment.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-01-24
Type: Fire Safety, Tag: 0923, Version: New
Description: Have proper medical gas storage and administration areas.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-01-24