Greenbough Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Greenbough Health and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF656Jan 8, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement comprehensive, person-centered care plans to address residents identified Activities of Daily Living (ADL) and skin integrity needs. The facility failed to develop a care plan related to nail care for (Residents #2, #21, and #24); failed to implement the care plan related to grooming and dressing (Resident #21); and failed to develop a care plan related to pressure ulcer prevention (Resident #4) for four (4) of 21 resident care plans reviewed. […]

• Actual harm, isolatedF686Jan 8, 2026

  Based on staff interviews, record reviews, and facility policy reviews, the facility failed to ensure the prevention of an avoidable pressure injury for one (1) of seven (7) residents with pressure ulcers, (Resident #4), and delayed treatment for one (1) of seven (7) residents with pressure ulcers. (Resident #58) Findings include: Review of facility policy titled Pressure Injury Prevention and Management, with a review date of 11/7/2025, revealed, Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. […]

• Actual harm, isolatedF656Jan 11, 2023

  Based on staff interview, record review and facility policy review the facility failed to develop and implement a comprehensive care plan for three (3) of 22 residents care plans reviewed. Resident's #7, #22, and #32. Findings include: Record review of the facility policy titled, Plans of Care with a revision date of 09/25/2017 revealed under Procedure .develop and implement an individualized person-centered comprehensive plan of care by the interdisciplinary team that includes but is not limited to -the attending physician, registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other staff or professionals in disciplines as determined by the resident's needs or as requested by the… […]

• Actual harm, isolatedF686Jan 11, 2023

  Based on observations, staff interviews, record reviews and facility policy review the facility failed to promote healing of pressures ulcers and prevent new ulcers from developing for one (1) of five (5)residents reviewed for pressure ulcers, Resident #22. Findings Include: Record review of the facility policy titled, Skin and Wound with a revision date of 01/24/22 revealed under Policy .To promote a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention and healing of pressure injuries. This review revealed under Process: Pressure Injury Prevention .#3 Nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record and under Skin Impairment Identification #1. […]

• No harm, potential for more than minimal, widespreadF882Jun 5, 2024

  Based on staff interview, record review, and facility policy review, the facility failed to ensure that the Infection Preventionist (IP) had completed the required training for the Infection Preventionist role for three (3) of three (3) survey days observed. Findings include: Record review of the facility policy Infection Prevention and Control Program with a revision date of October 2018 revealed under, Policy Interpretation and Implementation: .5. Coordination and Oversight a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). An interview on 6/04/2024 at 3:05 PM, Licensed Practical Nurse (LPN) #1 revealed she was the facility Infection Control nurse. […]