A list of the most recent deficiencies for Village at The Greene. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-01 | 2023-08-21 | Y |
| Have proper power supply for life support equipment. | Fire Safety | 2022-11-03 | 2023-02-24 | 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 | 2022-11-03 | 2023-02-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-03 | 2023-02-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-03 | 2023-02-13 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-12-13 | 2023-02-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-13 | 2023-02-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-13 | 2023-02-09 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-12-13 | 2023-02-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-13 | 2023-02-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-12-13 | 2023-02-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-13 | 2023-02-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-13 | 2023-02-09 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-12-13 | 2023-02-09 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-12-13 | 2023-02-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-13 | 2023-02-09 | N |
| Provide activities to meet all resident's needs. | Health | 2022-12-13 | 2023-02-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-13 | 2023-02-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-13 | 2023-02-09 | N |
| Provide appropriate foot care. | Health | 2022-12-13 | 2023-02-09 | 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 | 2022-12-13 | 2023-02-09 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-12-13 | 2023-02-09 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-12-13 | 2023-02-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-13 | 2023-02-09 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-12-13 | 2023-02-09 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-12-13 | 2023-02-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-13 | 2023-02-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-13 | 2023-02-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-13 | 2023-02-09 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-11-03 | 2023-02-03 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-11-03 | 2023-02-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-21 | 2022-01-12 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2020-01-09 | 2020-02-27 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-01-09 | 2020-02-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-09 | 2020-02-27 | 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 | 2020-01-09 | 2020-02-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-09 | 2020-02-27 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-01-09 | 2020-02-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-09 | 2020-02-27 | 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 | 2020-01-09 | 2020-02-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-09 | 2020-02-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-01-06 | 2020-02-27 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2020-01-06 | 2020-02-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-01-06 | 2020-02-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-06 | 2020-02-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-01-06 | 2020-02-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-06 | 2020-02-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-11-29 | 2019-01-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-11-29 | 2019-01-14 | 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 | 2018-11-29 | 2019-01-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-29 | 2019-01-14 | 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 | 2018-11-29 | 2019-01-14 | 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 | 2018-11-29 | 2019-01-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-11-29 | 2019-01-14 | N |
