Greenville Gardens

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 11, 2024

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1's safety while smoking. Resident #1 was allowed to sit on a public roadway in a space used by cars to parallel park where he could have been injured in a vehicle and pedestrian accident. An IJ was identified on 4/09/2024 at 3:45 PM. The IJ template was provided to the facility on [DATE] at 4:49 PM. […]

• Actual harm, isolatedF697Dec 8, 2021

  Based on observation, record review, and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 18 residents (Resident #64) reviewed for pain management. The facility did not provide Resident #68 with her available and ordered pain medication during an episode of acute pain on 12/6/21. As a result, Resident #68 suffered severe pain for at least an approximate hour. This failure could place residents at risk for unnecessary pain, discomfort and decreased quality of life. Findings included: Record review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF755Aug 13, 2025

  Based on observation, interview, and record review, the facility failed to establish a system of receipt of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, residents' safety, and drug diversion. […]

• No harm, potential for more than minimal, patternF880Aug 13, 2025

  Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #20 and Resident #11) reviewed for infection control. 1.The facility failed to ensure staff wore PPE when entering Resident #20's room on 08/12/25 and 08/13/25 who was on contact isolation for Extended-spectrum beta-lactamase also known as ESBL (a group of bacteria that are resistant to many commonly used antibiotics. 2. The facility failed to ensure LVN F used proper hand hygiene when preforming blood sugar checks and given insulin for Resident #11 on 08/12/25. […]

• No harm, potential for more than minimal, patternF925Aug 13, 2025

  Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for the memory care unit. The facility did not maintain an effective pest control program to ensure the memory care unit was free of gnats and other flying insects. This could place residents at risk for an unsanitary environment. Findings include:During an observation and attempted interview on 8/11/25 at 10:18 a.m., Resident #70 had gnats in her water cup that was at her bedside. There were also gnats flying around the room. Resident #70 resided on the locked unit. During an observation and attempted interview on 8/11/25 at 10:20 a.m. Resident #64 was standing inside his room watching the TV. He did not answer any questions. […]