A list of the most recent deficiencies for Greenhills Manor. 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? |
|---|---|---|---|---|
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-01-16 | 2024-02-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-01-16 | 2024-02-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-16 | 2024-02-15 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-01-16 | 2024-02-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-16 | 2024-02-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-16 | 2024-02-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-16 | 2024-02-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-16 | 2024-02-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-12 | 2024-02-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-01-12 | 2024-02-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-12 | 2024-02-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-12 | 2024-02-11 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-01-12 | 2024-02-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-12 | 2024-02-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-12 | 2024-02-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-12 | 2024-02-11 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-01-12 | 2024-02-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-12 | 2024-02-11 | 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 | 2024-01-12 | 2024-02-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-12 | 2024-02-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-12 | 2024-02-11 | N |
| Keep all essential equipment working safely. | Health | 2024-01-12 | 2024-02-11 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-01-12 | 2024-02-11 | 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 | 2022-12-05 | 2023-01-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-05 | 2023-01-04 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2022-12-05 | 2023-01-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-05 | 2023-01-04 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-15 | 2023-01-03 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-12-15 | 2023-01-03 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-12-15 | 2023-01-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-15 | 2023-01-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-15 | 2023-01-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-15 | 2023-01-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-15 | 2023-01-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-15 | 2023-01-03 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-12-05 | 2022-12-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-09-24 | 2019-10-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-24 | 2019-10-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-24 | 2019-10-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-24 | 2019-10-16 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-08-09 | 2019-08-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-09 | 2019-08-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-09 | 2019-08-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-09 | 2019-08-22 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-08-09 | 2019-08-22 | N |
