Greenway Health and Rehabilitation Center, LLC

In the surveyor’s words

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

• Immediate jeopardy, widespreadF835Apr 15, 2025

  Based on interviews, record review, review of the Job Description of the Administrator (ADM) and review of the facility's Abuse Policy, the facility's Administrator failed to identify and report sexual abuse in a timely manner to the State Agency. The ADM failed to thoroughly investigate an occurrence of sexual abuse to determine causal factors and develop an action plan for prevention of sexual abuse in the facility. On 01/13/2025 at approximately 2:00 AM, Licensed Practical Nurse (LPN) #13 observed Resident Identifier (RI) #20 sitting on RI #44's bed next to RI #44 who had severely impaired cognition and did not have the capacity to consent to the situation. […]

• Immediate jeopardy, widespreadF867Apr 15, 2025

  Based on interviews, record review, review of facility policies titled Abuse, Neglect and Exploitation and Quality Assessment and Assurance Committee, the facility's Quality Assurance and Performance Improvement (QAPI) committee, failed to review all allegations of abuse and injuries of unknown origin to ensure thorough investigations were conducted, investigations were conducted per facility policy, residents were protected, and reporting was timely. The Quality Assessment and Assurance (QAA or QAPI) committee did not review incidents of abuse that occurred to ensure the Abuse Policy was fully implemented for all allegations of abuse including staff identifying, stopping (protecting the resident from further abuse), and reporting abuse. […]

• Immediate jeopardy, patternF805Aug 17, 2023

  Based on interviews, record reviews, document review, and facility policy review, the facility failed to ensure residents who received mechanically altered diets were provided a meal consistent with their prescribed diet and of the appropriate texture and form to meet their individual needs. Further, the facility failed to ensure policies addressing the criteria for foods consistent with a mechanical soft diet were developed, implemented, and available to staff. Staff were not knowledgeable on what foods were acceptable for residents with orders for a mechanical soft diet. This failure affected 23 residents with orders for mechanical soft diets. […]

• Immediate jeopardy, isolatedF600Apr 15, 2025

  Based on interviews, resident record reviews, review of a facility policy titled Abuse, Neglect and Exploitation, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect the residents' right to be free from sexual, physical, and verbal abuse perpetrated by staff and residents. 1.) On 01/13/2025 at approximately 2:00 AM, Licensed Practical Nurse (LPN) #13 observed Resident Identifier (RI) #44's call light was on. The Certified Nursing Assistant (CNA) assigned to care for RI #44, CNA #23, was on her lunch break at that time and the CNA assigned to care for RI #20, CNA #12, was not permitted to enter RI #44's room. […]

• Immediate jeopardy, isolatedF609Apr 15, 2025

  Based on interviews, resident record reviews, review of a facility policy titled Abuse, Neglect and Exploitation, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to ensure an allegation of sexual abuse was reported to the State Agency within two hours. Specifically, on 01/13/2025 around 2:00 AM, Licensed Practical Nurse (LPN) #13 called the Administrator/Abuse Coordinator (ADM) and reported RI #20 had been witnessed nude from the waist down in RI #44's room, sitting on Resident Identifier (RI) #44's bed next to RI #44 caressing RI #44's hip and thigh. […]