Most Recent Deficiencies for GREELEY COUNTY HOSPITAL LTCU

Updated as of October 01, 2020

The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

The tables below are too small to fit on a phone. More information can be seen using a larger device such as a tablet, laptop, or desktop computer.

Deficiency Deficiency Date
Have properly located and lighted "Exit" signs. 2019-07-30
Follow proper procedures when the fire alarm was out of service for more than 4 hours. 2019-07-30
Inspect, test, and maintain automatic sprinkler systems. 2019-07-30
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. 2019-07-30
Be properly staffed 2019-07-30
Include a process for Emergency Preparedness collaboration. 2018-10-24
Address subsistence needs for staff and patients. 2018-10-24
Establish procedures for tracking staff and patients during an emergency. 2018-10-24
Establish policies and procedures for medical documentation. 2018-10-24
Establish policies and procedures for volunteers. 2018-10-24
Establish roles under a Waiver declared by secretary. 2018-10-24
Establish methods for sharing information. 2018-10-24
Provide a means of sharing information on occupancy/needs. 2018-10-24
Provide family notifications of emergency plan. 2018-10-24
Conduct testing and exercise requirements. 2018-10-24
Have properly located and lighted "Exit" signs. 2018-10-24
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. 2018-10-24
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. 2018-10-24
Have properly installed electrical wiring and gas equipment. 2018-10-24
Have simulated fire drills held at unexpected times. 2018-10-24
Ensure that smoke control systems are tested and documented in accordance with established engineering principles. 2018-10-24
Have generator or other power source capable of supplying service within 10 seconds. 2018-10-24
Ensure proper usage of power strips and extension cords. 2018-10-24
Keep aisles, corridors, and exits free of obstruction in case of emergency. 2017-01-04
Inspect, test, and maintain automatic sprinkler systems. 2017-01-04
Have restrictions on the use of portable space heaters. 2017-01-04
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. 2019-12-19
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 2018-11-15
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. 2018-11-15
Provide appropriate pressure ulcer care and prevent new ulcers from developing. 2018-11-15
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. 2018-11-15
Observe each nurse aide's job performance and give regular training. 2018-11-15
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. 2018-11-15
Ensure each resident?s drug regimen must be free from unnecessary drugs. 2018-11-15
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. 2018-11-15
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. 2017-07-12
Protect each resident from all abuse, physical punishment, and involuntary separation from others. 2017-07-12
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. 2017-07-12
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. 2017-07-12
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 2017-07-12
Provide medically-related social services to help each resident achieve the highest possible quality of life. 2017-07-12
Allow residents the right to participate in the planning or revision of care and treatment. 2017-07-12
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. 2017-07-12
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 2017-07-12
Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. 2017-07-12
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 2017-07-12
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. 2017-07-12
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. 2017-07-12
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. 2017-07-12