Greenhaven Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 4, 2025

  Based on observations, record review, and staff, physician, family and law enforcement interviews, the facility failed to supervise a severely cognitively impaired resident from exiting the facility without supervision. On 08/05/25 at approximately 8:30 pm Resident #1 followed Dietary Aide #1 out of the employee exit door and exited the facility. Resident #1 did have a wanderguard bracelet (component of a wander management system) on his left ankle; however, the door Resident #1 exited did not have a transmitter sensor and the magnetic lock was released when Dietary Aide #1 entered a code on the door keypad. […]

• Immediate jeopardy, isolatedF689Jul 8, 2025

  Based on record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to lock the brakes on a resident's wheelchair before leaving her unattended on the facility's front patio. Nurse Aide (NA) #5 positioned Resident #102 on the front patio and then walked away from the resident without securing the wheelchair brakes. Due to the brakes not being locked, and the resident's inability to stop the wheelchair when it began to roll due to weakness in all of her extremities, Resident #102 rolled approximately 10 feet across a circle drive and then struck her head on a brick wall which resulted in two lacerations to Resident #102's forehead that required sutures to repair. […]

• Actual harm, isolatedF600Apr 25, 2025

  Based on observation, record review and interviews with staff and family member, the facility failed to protect a resident's right to be free from sexual abuse (Resident #2). Resident #1 sexually abused Resident #2 while he was sleeping in his bed. The resident's family member believed the resident would have rejected a male's sexual advance, would have been angry, and was unable to protect himself. As Resident #2 was severely cognitively impaired, the reasonable person concept was applied. A reasonable person would have been traumatized by being sexually abused by a resident in their home environment making them feel angry, dehumanized, and powerless. This deficient practice affected 1 of 2 residents reviewed for abuse. […]

• Actual harm, isolatedF550Jan 13, 2023

  Based on record review, resident and staff interviews the facility failed to maintain the dignity of residents by not providing assistance with Activities of Daily Living (ADLs) when requested for 2 of 5 residents (Resident #19 and Resident #11) reviewed dignity. Resident #19 indicated she waited over 1 hour for her call bell to be answered and this made her feel ignored, bad, and resulted in the resident being tearful, and Resident #11 stated it made them feel mad. Finding included: 1. […]

• No harm, potential for more than minimal, patternF658Jul 8, 2025

  Based on interviews with staff and record reviews, the facility failed to clarify the dosage of aspirin to administer to 1 of 5 residents reviewed for unnecessary medications (Resident #66). The findings included: Resident #66 admitted to the facility on [DATE] with diagnoses including dementia, cerebral stroke syndrome, and cerebrovascular disease. Resident #66's quarterly Minimum Data Set (MDS) dated [DATE] documented she had severe cognitive impairment. The MDS noted she had a history of a stroke and she received antiplatelet medications (prevents the accumulation of platelets to prevent blood clots). Resident #66's Medication Administration Records (MAR) from January 2025-July 2025 were reviewed and included an order for staff to administer aspirin once every other day. […]