Greenwood Healthcare Center

In the surveyor’s words

From the most serious findings on record at Greenwood Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 8, 2025

  Based on observation, interview, and record review, the facility failed to provide supervision to prevent a resident that resided on a secured memory care unit and was to be receiving one to one staff supervision for exit seeking behavior, from exiting the secured memory care unit through a window in another resident's room. The resident was found by staff approximately 2 miles from the facility. (Resident B) The Immediate Jeopardy began on April 27, 2025, when Resident B exited the secured memory care unit through another residents window. The Administrator, Regional Nurse, and Assistant Director of Nursing were notified of the Immediate Jeopardy on May 6, 2025 at 2:00 p.m. […]

• No harm, potential for more than minimal, patternF812Jul 1, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was not stored beneath a water line on which water had condensed for 2 of 2 observations of the kitchen freezer. Findings include: During a tour of the facility's walk-in freezer, on 6/24/25 at 2:15 p.m. and 7/1/25 at 10:30 a.m., food was observed to be stored beneath the freezer condenser water line, upon which water had condensed and ice had formed. Beneath the freezer condenser were three boxes of cookie dough, two boxes of pizza dough, and two boxes of dinner rolls. Ice had fallen from the frozen condenser line onto the boxes. During an interview on 6/24/25 at 10:35 a.m., the Dietary Manager indicated there was ice formed on the leaking condenser and food was stored beneath the condenser. […]

• No harm, potential for more than minimal, patternF623Aug 12, 2024

  Based on record review and interview, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and/or the resident representative for 4 of 4 residents reviewed for hospitalization and discharge. (Resident 96, Resident 148, Resident 145, and Resident 160) Findings include: 1. On 8/9/24 at 1:00 p.m., Resident 96's clinical record was reviewed. The diagnoses included, but were not limited to, opioid dependence and acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). Residents 96's transfer forms indicated the resident was sent to the hospital on 5/12/24 and 6/23/24. […]

• No harm, potential for more than minimal, patternF625Aug 12, 2024

  Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 4 of 4 residents reviewed for hospitalization and discharge. (Resident 96, Resident 148, Resident 145, and Resident 160) Findings include: 1. On 8/9/24 at 1:00 p.m., Resident 96's clinical record was reviewed. The diagnoses included, but were not limited to, opioid dependence and acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). Residents 96's transfer forms, indicated the resident was sent to the hospital on 5/12/24 and 6/23/24. […]

• No harm, potential for more than minimal, patternF585May 24, 2022

  Based on interview and record review, the facility failed to ensure resident grievances were acted upon and promptly resolved for residents who had food complaints for 8 of 8 residents reviewed for food. (Resident 8, Resident 67, Resident 31, Resident 139, Resident 76, Resident 108, Resident 166, and Resident 98). Findings include: The following interviews were conducted during the survey. -On 5/17/22 at 3:03 p.m., Resident 8 indicated the food was terrible. -On 5/19/22 at 10:42 a.m., Resident 67 indicated the food was terrible. The food was tough and overcooked. -On 5/17/22 at 2:00 p.m., Resident 31 indicated the food sucks and just does not taste good. -On 5/18/22 at 3:33 p.m., Resident 139 indicated the food was terrible. […]