Deficiency Records for Willows of Greensburg
Updated as of September 01, 2020
This is not the most recent data for Willows of Greensburg. For the most recent information, click here.
A list of the most recent deficiencies for Willows of Greensburg. 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? |
|---|---|---|---|---|
| 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. | Fire Safety | 2019-06-11 | 2019-08-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-06-11 | 2019-08-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-11 | 2019-08-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-11 | 2019-08-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-11 | 2019-08-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-11 | 2019-08-08 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2019-06-11 | 2019-08-08 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-05-14 | 2019-06-13 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-05-14 | 2019-06-13 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-05-14 | 2019-06-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-14 | 2019-06-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-05-14 | 2019-06-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-14 | 2019-06-13 | 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 | 2019-05-14 | 2019-06-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-14 | 2019-06-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-14 | 2019-06-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-14 | 2019-06-13 | N |
| Meet other general requirements. | Fire Safety | 2018-06-20 | 2018-07-19 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2018-06-20 | 2018-07-19 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-06-20 | 2018-07-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-06-20 | 2018-07-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-06-20 | 2018-07-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-06-20 | 2018-07-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-06-20 | 2018-07-19 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-06-20 | 2018-07-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-06-20 | 2018-07-19 | N |
| Have an externally vented heating system. | Fire Safety | 2018-06-20 | 2018-07-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-06-20 | 2018-07-19 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-06-20 | 2018-07-19 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2018-06-20 | 2018-07-19 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-06-14 | 2018-07-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-14 | 2018-07-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-06-14 | 2018-07-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-14 | 2018-07-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-14 | 2018-07-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-14 | 2018-07-14 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-06-20 | 2018-07-06 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-06-20 | 2018-07-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-06-20 | 2018-07-06 | N |
| Have exits that are accessible at all times. | Fire Safety | 2017-06-20 | 2017-07-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-06-20 | 2017-07-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-06-20 | 2017-07-20 | N |
| Construct fire resistant interior walls. | Fire Safety | 2017-06-20 | 2017-07-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-20 | 2017-07-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-06-20 | 2017-07-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-06-20 | 2017-07-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-06-20 | 2017-07-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-06-20 | 2017-07-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-06-20 | 2017-07-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-06-20 | 2017-07-20 | N |
| Maintain comfortable and safe temperature levels. | Health | 2017-05-17 | 2017-06-16 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-05-17 | 2017-06-16 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-05-17 | 2017-06-16 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-05-17 | 2017-06-16 | N |
| Make sure that doctors visit residents regularly, as required. | Health | 2017-05-17 | 2017-06-16 | N |
