Greendale Forest Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Greendale Forest Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 27, 2025

  Based on record review and staff interviews, the facility failed to have effective systems in place for identifying the development of skin breakdown which delayed treatment and interventions. Resident #39's skin was intact on re-admission on 11/19/24. On 1/4/25 excoriation was noted on her buttocks. There were no further documented assessments until a wound assessment dated [DATE] recorded Resident #39 developed an unstageable (full thickness skin and tissue loss where the extent of tissue damage cannot be determined due to presence of slough, a yellow/white layer of dead skin tissue, or eschar, dry dead tissue, obscuring the wound bed) 5 centimeter (cm) by 5cm right buttocks pressure wound. […]

• Actual harm, isolatedF600Apr 26, 2024

  Based on observations, record review, staff and Physician interviews, the facility failed to protect the resident's right to be free from injury of unknown source that resulted in bruising under the eyes and a fracture of the bridge of the nasal bones. This occurred for 1 of 1 cognitively impaired resident reviewed for an injury of unknown source. (Resident #1) Findings included. Resident #1 was admitted to the facility on [DATE] with diagnoses including in part cerebral vascular accident (CVA), quadriplegia, and dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 had severely impaired cognition. She exhibited no physical or verbal behaviors directed toward others (e.g. hitting, kicking, grabbing, or yelling). […]

• No harm, potential for more than minimal, widespreadF727Jun 18, 2026

  Based on record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours per day seven days a week for 3 of 119 days (1/4/26, 2/8/26 and 3/15/26) reviewed for sufficient staffing.The findings included:A review of the daily posted nursing staff forms, daily nursing staff assignment sheets, and staff clock-in sheets from 1/1/26 through 3/31/26 and 5/18/26 through 6/18/26 was conducted.A review of the daily census posting sheets for 1/1/26 through 3/31/26 and 5/18/26 through 6/18/26 revealed no RN coverage for eight consecutive hours on 1/4/26, 2/8/26, and 3/15/26.On 6/18/26 at 9:53 AM the scheduler was interviewed. She could not recall the details of the dates of 1/4/26, 2/8/26, and 3/15/26 without any RN coverage. […]

• No harm, potential for more than minimal, patternF584Jun 18, 2026

  Based on observation and staff interviews, the facility failed to provide an environment free of wall damage (room [ROOM NUMBER], 707, and #710), failed to ensure pipes around hand washing sinks were sealed (room [ROOM NUMBER] and #307) and failed to provide privacy curtains free of stains (Rooms #408) for 6 of 26 rooms on 4 of 6 hallways reviewed for the environment. The findings included: 1A. An observation of room [ROOM NUMBER], which was occupied, took place on 6/15/26 at 11:58 AM and revealed deep scratch marks on the wall beside the residents bed, including a brownish-red dried substance in one of the marks and a large approximately 2 inch wide by 18 inch long by 1/2 deep gash in the sheetrock on the wall at the head of the bed. 1B. […]

• No harm, potential for more than minimal, patternF657Mar 27, 2025

  Based on record reviews and staff interviews, the facility failed to conduct and document care plan meetings after completion of quarterly and/or annual Minimum Data Set (MDS) assessments for 6 of 31 residents reviewed for care planning (Resident #27, Resident #100, Resident #91, Resident #45, Resident #18, and Resident #21). The findings included: 1. Resident #27 was admitted to the facility on [DATE]. The last care plan meeting documented in Resident #27's medical record was dated 7/9/2024. MDS assessments were completed for Resident #27 on the following dates: 9/16/2024 (quarterly), 11/11/2024 (quarterly), 1/10/2025 (quarterly) and 3/21/2025 (significant change). […]