Greendale Park Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Greendale Park Nursing and Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jul 18, 2024

  Based on interview and record review, the facility did not implement their written policies and procedures to prohibit and prevent abuse, for 1 CNA (Certified Nursing Assistant)-GG of 1 CNA reviewed who was involved in an allegation of sexual assault against 1 (R10) of 1 residents who alleged sexual assault. The deficient practice has the potential to affect a pattern of the 69 residents residing in the facility as the staff on night shift float to assist on other units. CNA-GG's BID (background information disclosure) form, completed by CNA-GG upon hire at the facility, was completed inaccurately as CNA-GG answered no for the question, Were you ever convicted of any crime anywhere including in federal, state, local, military and tribal courts? […]

• Immediate jeopardy, isolatedF757Oct 27, 2021

  Based on interview, record review and observation, the Facility failed to ensure that 2 (R7 & R3) of 2 Residents reviewed for anticoagulants was adequately monitored for therapeutic levels. * R7 was admitted to the facility on [DATE]. R7 had been on [MEDICATION(S)] 5 mg every night since prior to admission. The facility did not develop a base line care plan for [MEDICATION(S)] to address monitoring for signs/symptoms related to the use of [MEDICATION(S)]. R7's fall risk assessment placed R7 at 16, which is high risk for falls. On 9/15/21, R7 was found on the floor after falling out of bed. R7 indicated she hit her face on the floor and was observed to have an abrasion on her nose between her eyes. R7 was transferred to the hospital for an evaluation. […]

• Actual harm, isolatedF686Jan 27, 2026

  Based on observation, interview and record review the facility did not ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers and do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 4 (R41, R2, R60, and R10) of 6 residents reviewed for pressure injuries. R41 developed an avoidable left heel deep tissue injury that was not comprehensively assessed or measured since September 2025. […]

• Actual harm, isolatedF686Mar 19, 2025

  Based on observation, interviews, and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services to promote healing and prevent new injuries from developing for 1 of 2 (R3) residents reviewed for pressure injuries. R3's pressure injuries were not comprehensively assessed and treatment was not implemented timely. This deficient practice resulted in R3's development of a stage 3 pressure injury. Findings include: The facility policy titled Skin Assessment implemented 3/1/19 documents (in part) . . It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. 1. […]

• Actual harm, isolatedF686Jan 8, 2025

  Based on observation, interview, and record review the facility did not ensure 1 (R8) of 4 residents reviewed with pressure injuries had the necessary care and treatment to prevent and heal pressure injuries. R8 developed a facility acquired, unstageable pressure injury to their right great toe despite being at risk for the development of pressure injuries. R8's skin was not assessed upon admission and an individualized care plan was not developed based upon R8's risks and care needs. Assessments by the contracted wound care provider incorrectly identified the location of the wounds. Facility wound assessments were not comprehensive. […]