Greenwood Operations DBA Greenwood Center

In the surveyor’s words

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

• Immediate jeopardy, patternF726Feb 18, 2026

  Based on clinical record review and staff interviews, the facility failed to have sufficient nursing staff with the necessary competencies and skills to provide the required nursing and related services. This failure jeopardized resident safety and hindered the attainment or maintenance of the highest practicable physical, mental, and psychosocial wellbeing of each resident. This was particularly evident in the case of four nursing staff members: Staff B, C, D, and F, where a change in a resident's condition was not properly identified.Findings are as follows:Record review of a community reported complaint submitted to The Rhode Island Department of Health on [DATE] alleges that this facility provided Neglectful transport of a patient in a non-medical transport vehicle during [an] acute… […]

• Immediate jeopardy, patternF689Mar 22, 2024

  Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible, relative to maintaining safe water temperatures on 5 of 6 units. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023, states in part, .Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident. Burns related to hot water/liquids may also be due to spills and/or immersion. […]

• Immediate jeopardy, isolatedF684Feb 18, 2026

  Based on clinical record review and staff interviews, the facility failed to ensure medications were administered as ordered. Additionally, the facility failed to recognize a change in condition in a timely manner for 1 of 1 resident reviewed, who was transferred to the hospital by a non-medical transport company, after being found by facility staff to have experienced a change in mental status, a decrease in oxygen saturation levels, and who subsequently expired, Resident ID #1.Findings are as follows:Record review of a community reported complaint submitted to The Rhode Island Department of Health on [DATE] alleges that this facility provided Neglectful transport of a patient in a non medical transport vehicle during [an] acute medical emergency.Review of a facility policy last revised… […]

• Actual harm, isolatedF550Feb 18, 2026

  Based on clinical record review, and staff and resident interviews, the facility failed to protect and promote the rights of residents relative to preferences and privacy, for 2 of 3 residents reviewed, Resident ID #s 2 and 3.Findings are as follows:Review of the facility policy titled, Resident Rights Under Federal Law, states in part, .To treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their self-esteem and self-worth.To incorporate the resident's goals, preferences, and choices into care. 1. […]

• Actual harm, isolatedF760Feb 18, 2026

  Based on clinical record review and staff interviews, the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed who did not receive intravenous antibiotic therapy as ordered, Resident ID #1. Findings are as follows:Record review revealed the resident was admitted to the facility on [DATE] with a diagnosis including, but not limited to, a urinary tract infection (UTI).Review of the hospital Discharge summary dated [DATE] revealed the resident was to receive Meropenem (an antibiotic) 1 gram (g) in 50 milliliters (mL) of normal saline, intravenously every eight hours for six days. […]