Greenview Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF600Jul 3, 2025

  Based on interview, observation, and record review, the facility failed to ensure the residents had the right to be free from physical abuse and neglect for 3 (Resident #1, Resident #2, and Resident #3) of 9 residents reviewed for abuse and neglect. 1.The facility failed to provide continuous one to one monitoring for Resident #1 after repeated targeted aggressive behavior against Resident #2. An Immediate Jeopardy (IJ) situation was identified on 07/01/25 at 6:55 pm for failure #1.While the IJ was removed on 07/02/25 a 6:42 pm the facility remained out of compliance at a scope of isolated that with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. […]

• Immediate jeopardy, isolatedF689Jun 12, 2025

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents and hazards. The facility failed to ensure there was appropriate supervision on [DATE] when Resident #1, who resided on the secure unit, exited the secure unit, after RN A left the unit (to respond to a code after not being familiar with the CPR policy), and then one of the facility's side exits and got into the passenger seat of a parked fire truck in the parking lot. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:28pm. […]

• Immediate jeopardy, isolatedF689Jan 12, 2024

  Based on interviews, observations, and record review the facility failed to ensure each resident receives adequate supervision and assistive devices for one of twenty residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1's coffee cup was positioned properly at the upper right of his plate which led to him knocking it over. Resident #1 sustained 2nd degree burns to his bilateral inner thighs from the hot coffee. An IJ was identified on 01/11/2024 at 4:10 PM. While the IJ was removed on 01/12/2024, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. […]

• Actual harm, isolatedF689Apr 23, 2026

  Based on interviews and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 6 (Resident #1) reviewed for accident hazards and supervision.The facility failed to ensure Resident #1 was properly secured in her wheelchair on 4/20/2026, which resulted in the resident slipping out of her wheelchair onto the floor of the vehicle and suffering a fractured toe and shoulder pain.This failure placed the residents at risk of serious harm and a diminished quality of life.Findings included:Record review on 4/23/2026 of Resident #1's admission record reflected a [AGE] year-old female, originally admitted to the facility on [DATE]. […]

• Actual harm, isolatedF686Jun 12, 2025

  Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable, and a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for one 1 (Resident #3) of six residents reviewed for quality of care. The facility failed to complete weekly skin assessments, obtain wound care orders and a therapy consult for Resident #3, causing his wound to deteriorate. […]