Greenwich Woods Rehabilitation

In the surveyor’s words

From the most serious findings on record at Greenwich Woods Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Mar 19, 2025

  Based on observations, review of facility documentation, and interviews, the facility failed to follow the manufacturers' recommendations for replacing the Nephros water filters which were in place since [DATE], following a presumptive positive case of Legionella in a resident at the facility, and the facility failed to ensure that a positive Legionella water sample was reported to the State Agency in a timely manner. These failures resulted in the finding of Immediate Jeopardy. The findings include: The daily census report dated [DATE] identified a resident census of 83. The facility's total capacity is 217. The facility's layout consists of two floors with resident units on both floors. […]

• Actual harm, isolatedF689Nov 15, 2024

  Based on a review of clinical records, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, (Resident #2), the facility failed to ensure a resident who is completely dependent on staff for transfers, wheelchair mobility, bed mobility and Activities of Daily Living (ADLs) remained free from significant injuries of unknown origin including bilateral (both sides) femur (bone in upper thigh) fractures. The findings include: Resident #2 had diagnoses that included vascular dementia, anxiety, depression, bipolar, and atrial fibrillation. […]

• No harm, potential for more than minimal, patternF658Mar 19, 2025

  Based on observations, review of clinical records, review of facility policy/procedures and interviews for two of three sampled residents (Resident #33 and Resident #336) observed with medications at the bedside, the facility failed to ensure that medications were administered according to acceptable standards of practice and the facility failed to ensure that medication was not left at the resident's bedside for a resident who is without an order or assessment for self-administration. The findings include: 1. Resident #33's diagnoses included chronic diastolic congestive heart failure, hypoxemia, and acute cough. […]

• No harm, potential for more than minimal, patternF689Mar 19, 2025

  Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews, the facility failed to ensure the second-floor windows contained mechanisms to prevent them from fully opening, presenting a safety hazard to residents residing on the unit (dementia unit). The findings include: Observation on 3/10/25 at 10:05 AM identified in room [ROOM NUMBER](a resident room), the window was fully opened, and did not contain a screen. The degree to which the window was opened presented a safety hazard to residents who were able to access the window. Interview with NA #2 on 3/10/25 at 10:10 AM indicated that she was providing care to a resident in that room with NA#1 and NA #1 opened the window because it was very hot in the room. […]

• No harm, potential for more than minimal, patternF726Mar 19, 2025

  Based on review of facility documentation, facility policy, and interviews, the facility failed to complete license nurses and nurse aides education and competencies related to intravenous therapy (IV) therapy and the facility failed to ensure licensed nurses had intravenous therapy (IV) certificate. The findings included: 1. Review of the State Agency documentation identified the facility has a licensed bed capacity of 217 and an IV therapy program. Review of the census daily report dated 3/10/25 identified the facility census was 83 residents in the facility. A request was made on 3/17/25 for documentation of the annual licensed nurses and nurse aides IV competencies for 2023. The facility failed to provide any documentation regarding the completion of 2023 annual competencies. […]