Greenwood Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF656Jul 5, 2022

  Based on observation, interview, record and review of facility policy, it was determined the facility failed to implement a comprehensive person-centered care plan for each resident that includes measurable objectives to meet the resident's medical, and nursing needs for two (2) of forty-seven (47) sampled residents (Residents #68 and #75). On 05/19/2022, Resident #75 fell to the floor while ambulating in the hallway, hitting his/her head and was noted to have bleeding above the left eyebrow and, also a tooth was noted to be dislodged. The resident became confused, pupils were assessed as unequal and sluggish, and he/she lost consciousness. […]

• Actual harm, isolatedF689Jul 5, 2022

  Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident was provided adequate supervision and assistance devices to prevent falls for one (1) of forty-seven (47) sampled residents (Resident #75). Resident #75 had a history of falls, sustaining eleven (11) falls from 01/17/2022 to 05/18/2022. On 05/19/2022, the resident fell to the floor while ambulating in the hallway, hitting his/her head and was noted to have bleeding above the left eyebrow and, also a tooth was noted to be dislodged. Further, the resident became confused, pupils were assessed as unequal and sluggish, and the resident lost consciousness and was transferred to the local hospital Emergency Department (ED). […]

• No harm, potential for more than minimal, widespreadF880Jul 5, 2022

  Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control (IPC) program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19. Observation, on 06/28/2022, revealed Certified Nursing Assistant (CNA) #2 was working on the 200 Hall and took a rolling vital sign machine into room [ROOM NUMBER]. […]

• No harm, potential for more than minimal, patternF921Aug 1, 2025

  Based on observation and interview, the facility failed to ensure a functional, sanitary, environment for residents, staff and the public. Observation of the facility's back 300 Hall revealed water damage to the ceilings, which affected two residents (Resident (R)99 and R106) and had the potential to affect any of the 28 residents residing on the hall.The findings include: 1. Observation on 07/29/2025 at 3:06 PM, revealed Licensed Practical Nurse (LPN) 1 was in the 300 Back Hall, which housed 28 residents. Per observation, a large wet spot was noted on the carpet, and a bucket filled with water and a soiled glove were on the floor, directly under an approximately 2-inch-long hole in the hallway's ceiling. […]

• No harm, potential for more than minimal, isolatedF641Aug 1, 2025

  Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1, the facility failed to ensure its Minimum Sata Set (MDS) Assessments accurately reflected the status of 1 of 1 sampled residents, (Resident [R] 8).The findings include: Review of a statement provided by the facility, dated 08/01/2025 and signed by the Director of Nursing (DON), Minimum Data Set Nurse (MDS) 1, and the Administrator, revealed the facility does not have a specific policy on MDS, we follow state/federal guidelines and the RAI. […]