Greenspring Village

In the surveyor’s words

From the most serious findings on record at Greenspring Village, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 6, 2025

  Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to implement interventions to prevent the development of a pressure ulcer for one resident, Resident #1 (R1) of 33 residents in the survey sample, which resulted in a facility acquired wound that was identified at the advanced stage 3, constituting harm. The findings included: According to the clinical record, R1 was admitted to the facility on [DATE]. Diagnoses for R1 included but are not limited to muscle weakness, osteoarthritis, venous insufficiency, dementia, and lack of coordination. […]

• No harm, potential for more than minimal, patternF574Mar 6, 2025

  Based on resident interview, staff interview and facility documentation review, the facility staff failed to ensure that five residents, (Resident #4 (R4), Resident #8 (R8), Resident #22 (R22), Resident #30 (R30), and Resident #309 (R309)), had the information on how to file a complaint with the state licensure office and state survey agency in a survey sample of 33 residents. The findings included: The facility failed to make sure all residents was aware of how to file a complaint with the state licensure office and state survey agency. On 3/3/25 at 2:00 p.m., a resident council meeting was conducted. […]

• No harm, potential for more than minimal, patternF585Mar 6, 2025

  Based on observation, resident interviews, staff interviews and facility documentation, the facility staff failed to ensure that five residents,( Resident #4 (R4), Resident #8 (R8), Resident #22 (R22), Resident #30 (R30) and Resident #309 (R309), had the information on how to file a grievance out of a survey of 33 residents. The findings included: The facility staff failed to provide the information to the residents on how to file a grievance, where grievance forms are located, and who the grievance officer was for the healthcare residents on Unit 200 and 300. On 3/3/25 at 2:00 p.m. a resident council meeting was conducted, which was attended by R4, R8, R22, R30, and R309. The five residents stated that they were not aware of what a grievance form was or how to file a grievance. […]

• No harm, potential for more than minimal, patternF607Mar 6, 2025

  Based on staff interview and facility documentation review, the facility staff failed to implement their abuse policy with regards to the pre-screening of employees for 12 of 25 (Staff C, E, G, H, I, K, M, P, S, U, W, and X) employee/staff records reviewed. The findings included: 1. For Staff U, the facility staff permitted the employee to work 20 months without knowing the status of their criminal background check and if they had been convicted of any barrier crimes. On [DATE], a sample of 25 staff records was selected for review for pre-screening requirements. Staff U's file was provided, which indicated she was a certified nursing assistant (CNA) and was hired [DATE]. […]

• No harm, potential for more than minimal, patternF756Mar 6, 2025

  Based on staff interview, clinical record review and facility documentation review the facility staff failed to respond to medication reviews in a timely manner for three residents Resident #6 (R6), Resident #9 (R9) and Resident #31 (R31) out of a survey sample of 33 residents. The findings included: 1. The facility staff failed to review and respond to pharmacy consults in a timely manner. R6 was admitted to the facility on [DATE]. Diagnoses for R6 included but are not limited to unspecified psychosis, bipolar disorder and anxiety disorder. R6's Quarterly Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 1/11/2025 coded R6 with no cognitive impairment. On 3/5/25 at approximately at 9:00 a.m. an interview was conducted with the registered nurse, RN#1 (RN1). […]