GOOD SAMARITAN SOCIETY - COLONIAL VILLA

Nursing Home Inspector

719 NORTH BROWN STREET
ALMA, NE 68920
Harlan County
Phone: 308-928-2128
Provider Number: 285185
Last Inspection: 12/01/2016

About the Nursing Home

Number of Beds: 53
Number of Residents: 34
Beds Available: 19
Percent Occupancy: 64%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

14

Facility
14

County
20

NE
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

14

2016
18

2015
30

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

12/1/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 12/29/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Widespread : Minimal 5 12/29/2016
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 12/29/2016
 

12/15/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 1/12/2016
 
Failed To: Provide housekeeping and maintenance services. Isolated : Minimal 3 1/12/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 1/12/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 1/12/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 1/12/2016
 

12/8/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 1/22/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 1/22/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 1/22/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 1/22/2015
 
Failed To: Give each resident enough fluids to keep them healthy and prevent dehydration. Isolated : Minimal 3 1/22/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Isolated : Minimal 3 1/22/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 1/22/2015
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 1/22/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NE State Avg
Number of Residents 34 34.00 53.60
Registered Nurses 0.67 0.67 0.76
Licensed Practical / Vocational Nurses 0.48 0.48 0.68
Certified Nursing Assistants 2.72 2.72 2.49
Total Staff Hours 3.86 3.86 3.93

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NE State Avg%
of high risk long-stay residents with pressure ulcers 10 10 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 100 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100 100 96
of long-stay residents experiencing one or more falls with major injury 4 4 4
of long-stay residents who have depressive symptoms 0 0 5
of long-stay residents who lose too much weight 11 11 7
of long-stay residents who received an antianxiety or hypnotic medication 20 20 21
of long-stay residents who received an antipsychotic medication 10 10 18
of long-stay residents who self-report moderate to severe pain 8 8 9
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 21 21 19
of long-stay residents whose need for help with daily activities has increased 16 16 15
of long-stay residents with a catheter inserted and left in their bladder 6 6 2
of long-stay residents with a urinary tract infection 1 1 5
of low risk long-stay residents who lose control of their bowels or bladder 43 43 46
of short-stay residents assessed and appropriately given the pneumococcal vaccine 95 95 83
of short-stay residents who newly received an antipsychotic medication 0 Not Available   8
of short-stay residents who self-report moderate to severe pain 24 Not Available   75
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 72 0 2
of short-stay residents with pressure ulcers that are new or worsened 0 24 19