Deficiency Records for Willows of Greensburg
Updated as of March 01, 2023
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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Develop a communication plan. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| 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 | 2022-03-22 | 2022-04-22 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-03-22 | 2022-04-22 | 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 | 2022-03-22 | 2022-04-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-07 | 2022-04-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-07 | 2022-04-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-07 | 2022-04-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-07 | 2022-04-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-07 | 2022-04-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-07 | 2022-04-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-07 | 2022-04-12 | 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 | 2022-03-07 | 2022-04-12 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-03-07 | 2022-04-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-15 | 2021-07-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-19 | 2021-05-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-19 | 2021-05-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-04-19 | 2021-05-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-19 | 2021-05-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-04-19 | 2021-05-19 | 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 | 2021-04-19 | 2021-05-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-19 | 2021-05-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-28 | 2021-05-19 | 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 | 2021-04-28 | 2021-05-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-02-23 | 2021-03-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-12-03 | 2021-01-11 | N |
| 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 |
