Greendale Forest Nursing and Rehabilitation Center

Inspectors wroteBased on record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours per day seven days a week for 3 of 119 days (1/4/26, 2/8/26 and 3/15/26) reviewed for sufficient staffing.

Inspectors wroteBased on observation and staff interviews, the facility failed to provide an environment free of wall damage (room [ROOM NUMBER], 707, and #710), failed to ensure pipes around hand washing sinks were sealed (room [ROOM NUMBER] and #307) and failed to provide privacy curtains free of stains (Rooms #408) for 6 of 26 rooms on 4 of 6 hallways reviewed for the environment.

Inspectors wroteBased on record review, Physician #1, Physician #2, Hospice staff interview and staff interviews the facility failed to implement effective interventions to promote bowel movements. Hospice orders on 2/7/26 included the addition of a stool softener as needed; however, the bowel regimen did not begin until 2/18/26 when the resident returned from the emergency department (ED) on 2/18/26. A pelvic x-ray was performed in the ED on 2/18/26 that displayed fecal impaction. This was for 1 of 1 resident (Resident #16) reviewed for professional standards.

Inspectors wroteBased on observation, record review, resident, staff and physician interviews the facility failed to arrange podiatry services for 1 of 1 resident reviewed for foot care (Resident #89).

Inspectors wroteBased on record review, Physician #1, Physician #2, Hospice Clinical Manger, the Hospice Nurse and staff interviews, the facility failed to have effective systems in place to ensure hospice orders were processed when a resident was admitted to hospice services for 1 of 1 resident reviewed for hospice services (Resident #16).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure an accurate Medication Administration Record (MAR) when staff documented a scheduled blood draw (a procedure in which a needle is used to take blood from a vein, usually for laboratory testing) was completed twice a week instead of once a week for 1 of 3 residents reviewed for blood draws (Resident #2).

Inspectors wroteBased on record review and staff interviews, the facility failed to have effective systems in place for identifying the development of skin breakdown which delayed treatment and interventions. Resident #39's skin was intact on re-admission on [DATE]. On 1/4/25 excoriation was noted on her buttocks. There were no further documented assessments until a wound assessment dated [DATE] recorded Resident #39 developed an unstageable (full thickness skin and tissue loss where the extent of tissue damage cannot be determined due to presence of slough, a yellow/white layer of dead skin tissue, or eschar, dry dead tissue, obscuring the wound bed) 5 centimeter (cm) by 5cm right buttocks pressure wound. Resident #39's right buttocks pressure wound deteriorated and required hospitalization for an infected right buttocks/sacral pressure wound on 2/17/2025. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to conduct and document care plan meetings after completion of quarterly and/or annual Minimum Data Set (MDS) assessments for 6 of 31 residents reviewed for care planning (Resident #27, Resident #100, Resident #91, Resident #45, Resident #18, and Resident #21).

Inspectors wroteBased on record review, observations, and staff interviews the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 3 of 3 residents reviewed with urinary catheters (Resident # 8, Resident # 5 and Resident # 14).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to administer supplemental oxygen as prescribed by the physician for 1 of 1 resident reviewed for oxygen use (Resident #27).

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to maintain an accurate medical record in documenting the administration of oxygen for 1 of 31 residents whose medical records were reviewed (Resident #27).

Inspectors wroteBased on observations and staff interviews, the facility failed to provide a clean and sanitary environment by not removing a dark grey/black colored substance from 20 of 25 ceiling fans observed on 8 of 8 resident halls.

Inspectors wroteBased on record review and staff interviews, the facility failed to post accurate Registered Nurse (RN) staffing information for 16 of 114 days reviewed for posted nurse staffing (12/9/24, 12/16/24, 12/30/24, 1/4/25, 1/14/25, 1/22/25, 1/27/25, 1/28/25, 1/30/25, 2/7/25, 2/17/25, 2/21/25, 2/23/25, 2/28/25, 3/11/25, and 3/16/25).

Inspectors wroteBased on observations, record review, staff and Physician interviews, the facility failed to protect the resident's right to be free from injury of unknown source that resulted in bruising under the eyes and a fracture of the bridge of the nasal bones. This occurred for 1 of 1 cognitively impaired resident reviewed for an injury of unknown source. (Resident #1)

Inspectors wroteBased on observations, record review, staff and Physician interviews the facility failed to notify the Physician of a residents change in condition when an injury of unknown source was identified. The resident was observed with unexplained bruising and swelling under the eye and x-rays confirmed a fracture of the bridge of the nasal bones. This occurred for 1 of 1 cognitively impaired resident (Resident #1) reviewed for an injury of unknown source and notification of the Physician.

Inspectors wroteBased on record review and staff interviews the facility failed to implement their policy for injuries of unknown source that required facility staff to immediately report the injury to facility management. A staff member failed to report unexplained bruising under the eyes and over the nose to facility management as soon as the injury was observed for 1 of 1 residents (Resident #1) reviewed for injuries of unknown source.

Inspectors wroteBased on record review, staff and Physician interviews the facility failed to monitor a resident following the identification of an injury of unknown source that resulted in bruising and a fracture of the nasal bridge. Neurological checks were not conducted following the unwitnessed head injury, vital signs were not obtained, and pain assessments were not conducted. This occurred for 1 of 1 cognitively impaired resident reviewed for an injury of unknown source. (Resident #1)

Inspectors wroteBased on observation, staff interviews and review of the daily nursing staff postings, the facility failed to post accurate census numbers for 35 of 35 days.

Inspectors wroteBased on observations, resident interviews and staff interviews, the facility failed to inform residents (Resident #11, Resident #6 and Resident #22) of the location of the state inspection results and failed to display state inspection results in a location accessible to residents for 3 of 14 residents present in a Resident Council meeting.

Inspectors wroteBased on staff interviews, interview with the Ombudsman and record review, the facility failed to provide a copy of the transfer/discharge notice to the Ombudsman for 1 of 1 resident (Resident #78) reviewed for hospitalization.