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Deficiency Records for The Greens at Pinehurst Rehab and Living Center
A list of the most recent deficiencies for The Greens at Pinehurst Rehab and Living Center. 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 Greens at Pinehurst Rehab and Living Center. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-01 | 2023-12-15 | 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 | 2023-11-01 | 2023-12-15 | 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 | 2023-11-01 | 2023-12-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-28 | 2023-10-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-10-20 | Y |
| 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 | 2023-09-28 | 2023-10-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-28 | 2023-10-19 | 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 | 2023-09-28 | 2023-10-19 | 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 | 2023-09-28 | 2023-10-19 | 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 | 2023-09-28 | 2023-10-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-28 | 2023-10-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-28 | 2023-10-19 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-28 | 2023-10-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-28 | 2023-10-19 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-23 | 2022-09-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-23 | 2022-09-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-23 | 2022-09-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-23 | 2022-09-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-07-20 | 2022-08-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-20 | 2022-08-08 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-07-20 | 2022-08-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-20 | 2022-08-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-20 | 2022-08-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-20 | 2022-08-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-20 | 2022-08-08 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-07-20 | 2022-08-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-20 | 2022-08-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-20 | 2022-08-08 | N |
| 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. | Health | 2022-07-20 | 2022-08-08 | N |
| Post nurse staffing information every day. | Health | 2022-07-20 | 2022-08-08 | 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 | 2022-07-20 | 2022-08-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-20 | 2022-08-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-07-20 | 2022-08-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-20 | 2022-08-08 | 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 | 2022-07-20 | 2022-08-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-20 | 2022-03-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-20 | 2021-10-11 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-09-20 | 2021-10-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-20 | 2021-10-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-20 | 2021-10-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-20 | 2021-10-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-20 | 2021-10-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-20 | 2021-09-21 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-09-20 | 2021-09-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-20 | 2021-09-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-20 | 2021-09-21 | 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 | 2021-09-20 | 2021-09-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-20 | 2021-09-21 | 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 | 2021-09-20 | 2021-09-21 | 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 | 2021-09-20 | 2021-09-21 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-09-20 | 2021-09-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-20 | 2021-09-21 | N |
| Keep all essential equipment working safely. | Health | 2021-09-20 | 2021-09-21 | 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 | 2021-03-31 | 2021-04-26 | N |
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