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Deficiency Records for Greenbrier Regional Medical Center
A list of the most recent deficiencies for Greenbrier Regional Medical 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 Greenbrier Regional Medical 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-22 | 2021-09-05 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-07-22 | 2021-09-05 | 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 | 2021-07-22 | 2021-09-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-07-22 | 2021-09-05 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-07-22 | 2021-09-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-22 | 2021-09-05 | 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 | 2021-07-22 | 2021-09-05 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-07-22 | 2021-09-05 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-07-22 | 2021-09-05 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-07-22 | 2021-09-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-22 | 2021-09-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-22 | 2021-09-05 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-07-22 | 2021-09-05 | 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 | 2021-07-22 | 2021-09-05 | N |
| Dispose of garbage and refuse properly. | Health | 2021-07-22 | 2021-09-05 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2021-07-22 | 2021-09-05 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-07-22 | 2021-09-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-07-22 | 2021-09-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-07-22 | 2021-09-05 | 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 | 2021-07-29 | 2021-08-24 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-07-29 | 2021-08-24 | N |
| Meet fire sprinkler requirement for tall buildings. | Fire Safety | 2021-07-29 | 2021-08-24 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-07-29 | 2021-08-24 | 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 | 2021-07-22 | 2021-06-21 | N |
| Meet other general requirements. | Fire Safety | 2019-05-15 | 2020-12-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-05-15 | 2019-08-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-15 | 2019-08-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-15 | 2019-08-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-16 | 2019-05-31 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-04-16 | 2019-05-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-16 | 2019-05-31 | 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 | 2019-04-16 | 2019-05-31 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-04-16 | 2019-05-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-16 | 2019-05-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-04-16 | 2019-05-31 | 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 | 2019-04-16 | 2019-05-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-16 | 2019-05-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-16 | 2019-05-31 | N |
| Provide appropriate foot care. | Health | 2019-04-16 | 2019-05-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-16 | 2019-05-31 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-04-16 | 2019-05-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-16 | 2019-05-31 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-04-16 | 2019-05-31 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-04-16 | 2019-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-16 | 2019-05-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Develop a communication plan. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Establish methods for sharing information. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-08-24 | 2017-11-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-08-24 | 2017-10-02 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2017-08-24 | 2017-10-02 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2017-08-24 | 2017-10-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-24 | 2017-10-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-08-24 | 2017-10-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-08-24 | 2017-10-02 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-08-24 | 2017-10-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-08-24 | 2017-10-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2017-08-24 | 2017-10-02 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2017-08-24 | 2017-10-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-08-24 | 2017-10-02 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2017-07-27 | 2017-09-06 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-07-27 | 2017-09-06 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-07-27 | 2017-09-06 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-07-27 | 2017-09-06 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-07-27 | 2017-09-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-07-27 | 2017-09-06 | N |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2017-07-27 | 2017-09-06 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2017-07-27 | 2017-09-06 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-07-27 | 2017-09-06 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-07-27 | 2017-09-06 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-07-27 | 2017-09-06 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-07-27 | 2017-09-06 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-07-27 | 2017-09-06 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-07-27 | 2017-09-06 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2017-07-27 | 2017-09-06 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-07-27 | 2017-09-06 | N |
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