Edenbrook of Greenwood Hill

In the surveyor’s words

From the most serious findings on record at Edenbrook of Greenwood Hill, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 13, 2025

  Based on review of clinical records, the facility's abuse prohibition policy, and select investigative reports and interviews with staff and residents it was determined the facility failed to ensure that one resident (Resident 1) was free from sexual abuse perpetrated by a facility staff member out of 6 residents sampled. This failure to prevent, identify, and respond appropriately to sexual abuse placed Resident 1 and all other residents in the facility at risk for further harm, resulting in Immediate Jeopardy. Findings include: A review of a facility policy entitled Abuse and Neglect Prevention revealed it is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment, or exploitation. […]

• Actual harm, isolatedF600Aug 8, 2025

  Based on a review of closed clinical records, select facility policy, documentation provided by the facility, and staff interviews, it was determined the facility displayed past non-compliance by failing to protect one out of four residents sampled (Resident 117) from neglect by not ensuring required vehicle safety devices were in place during transportation, resulting in actual harm in the form of a laceration requiring staples. Findings include: A review of the facility policy titled Vulnerable Adult Abuse and Neglect Prevention, last reviewed by the facility June 19, 2025, revealed it is the facility policy to provide professional care and services in an environment that is free from any type of neglect. […]

• Actual harm, isolatedF656Jan 18, 2024

  Based on review of clinical records, select incident reports and information submitted by the facility and staff interview it was determined that the facility failed to develop and implement a resident's person-centered comprehensive care plan in a manner that assures staff are aware of the resident's specific transfer needs to meet the objective of safe transfers, to prevent a fall with a serious injury, a left hip fracture, for one resident out of four sampled (Resident 70). Findings included: A review of Resident 70's clinical record revealed that the resident had diagnoses of a left leg above the knee amputation, cerebral infarction (stroke), muscle weakness, lack of coordination, abnormalities of gait and mobility, abnormal posture, and left femur (leg) fracture. […]

• Actual harm, isolatedF600Mar 29, 2023

  Based on a review of select facility policy, clinical records and select facility reports and interviews with staff, it was determined that the facility failed to ensure that one out of seven residents reviewed was free from physical abuse (Resident 1) perpetrated by another resident (Resident 2), which resulted in actual harm of a fractured wrist to Resident 1. Findings include: A review of the current facility policy titled Abuse Policy reviewed by the facility December 2022, revealed that residents have the right to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion, noting that No abuse or harm of any type will be tolerated. […]

• Actual harm, isolatedF686Mar 19, 2021

  Based on a review of clinical records and staff interviews it was determined that the facility failed to consistently provide care and services, consistent with professional standards of practice, to accurately assess skin impairment and to prevent the development and/or worsening of pressure sores, which included complications of infection and pain, for two of three residents reviewed with pressure sores (Resident 59 and 77). Findings: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. […]