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Deficiency Records for The Waters of Greencastle
A list of the most recent deficiencies for The Waters of Greencastle. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for The Waters of Greencastle. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-06 | 2023-10-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-09-06 | 2023-09-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-15 | 2023-09-12 | 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 | 2023-08-15 | 2023-09-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-15 | 2023-09-12 | 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 | 2023-08-15 | 2023-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-15 | 2023-09-12 | N |
| Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. | Health | 2023-08-15 | 2023-09-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-15 | 2023-09-12 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-09-06 | 2023-09-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-06 | 2023-09-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-09-06 | 2023-09-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-06 | 2023-09-07 | 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 | 2023-08-15 | 2023-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-15 | 2023-04-03 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-08-15 | 2023-04-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-27 | 2022-08-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-27 | 2022-07-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-27 | 2022-07-29 | 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 | 2022-06-27 | 2022-07-12 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-06-27 | 2022-07-11 | 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 | 2022-06-27 | 2022-06-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-27 | 2022-06-28 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-05-25 | 2022-06-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-25 | 2022-06-16 | 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 | 2022-05-25 | 2022-06-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-25 | 2022-06-16 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-05-25 | 2022-06-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-25 | 2022-06-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-25 | 2022-06-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-25 | 2022-06-16 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-17 | 2019-10-16 | N |
| Meet other general requirements. | Fire Safety | 2019-09-17 | 2019-10-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-17 | 2019-10-04 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-09-17 | 2019-10-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-17 | 2019-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-17 | 2019-10-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-09-17 | 2019-10-04 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-09-17 | 2019-10-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-17 | 2019-10-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-17 | 2019-10-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-17 | 2019-10-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-19 | 2019-08-17 | 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 | 2019-07-19 | 2019-08-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-19 | 2019-08-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-19 | 2019-08-17 | 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 | 2019-07-19 | 2019-08-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-19 | 2019-08-17 | 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 | 2019-07-19 | 2019-08-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-07-19 | 2019-08-17 | 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 | 2019-07-19 | 2019-08-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-07-19 | 2019-08-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-19 | 2019-08-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-07-19 | 2019-08-17 | N |
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