Greenleaf Health Campus

Inspectors wroteBased on record review and interview, the facility failed to ensure clinical records were accurate and complete related to assessments completed after a change in condition for 1 of 3 residents reviewed for change of condition. (Resident E)

Inspectors wroteBased on record review and interviews, the facility failed to ensure resident and resident group grievances regarding call lights were answered in a timely manner. During a Resident Council Meeting on 9/23/2025 at 2:08 P.M. 4 of 5 residents indicated call light wait times are 20-30 minutes or more and this happens 3-4 times a week, especially at night. At times they are told by the aide they will be back but never come back. A review of past Resident Council minutes indicated call light response times were a concern on 7/14/2025, 8/15/2025, and 9/5/2025. During an interview on 9/24/2025 at 8:22 P.M., LPN 8 indicated she there were 2 CNAs on the 300 hall, which was normal. During an interview on 9/24/2025 at 8:46 P.M., the ED indicated there was 1 nurse and 1 CNA working the 100 hall and 1 QMA and 2 CNAs on the 200 hall. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure nursing staff had the competencies to administer medications timely and/or sign off medications immediately after administration for 4 of 5 residents reviewed for medications. ( Residents 3, 10, 37, and 64) This deficient practice involved the following staff: QMA 5, QMA 7, RN 8, RN9, QMA 10, LPN11, RN12, QMA 13, LPN 14, QMA 15, RN 16 and RN 17Findings include:1. A record review for Resident 3 was completed on 9/24/2025 at 9:18 A.M. Diagnoses included, but were not limited to, type 2 diabetes mellitus, dementia without behaviors, generalized anxiety disorder, and atrial fibrillation. Physician Orders for Resident 3 included, but were not limited to: -calcium citrate (supplement) 250 milligram (mg) by mouth twice a day. -carbamazepine (antiseizure) 300 mg by mouth twice a day. -carbamazepine 100 mg by mouth once a day. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain oxygen equipment in a sanitary manner related to dating oxygen tubing and cleaning equipment for 3 of 9 residents who were reviewed. (Residents 64, 60 and 21)

Inspectors wroteBased on interview and record review, the facility failed to have a process for residents to file a grievance anonymously. This had the potential to affect 57 of 57 residents who resided in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure staff followed a care plan requiring resident care to be performed in pairs for 1 of 16 residents whose care plans were reviewed. (Resident 1)

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a skin condition and notify the physician of a change in condition for 1 of 1 resident reviewed for skin conditions. (Resident 36)

Inspectors wroteBased on record review and interview, the facility failed to follow a Pharmacist's recommendation related to obtaining blood laboratory work for 1 of 5 resident's who were reviewed for unnecessary medications. (Resident 64)

Inspectors wroteBased on observation, record review and interview, the facility failed to store food under sanitary conditions related to foods not tightly sealed, outdated foods and dirty kitchen equipment. In addition, the facility failed to prepare and serve food related to staff members not wearing hair nets as required for 2 of 2 kitchens observed. (Main and Activities kitchen) This issue had the potential to affect 57 of 57 residents who resided in the facility and received food from this dietary kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report a fall resulting in major injury to the Indiana Department of Health (IDOH) for a resident requiring hospitalization greater than 23 hours, for one of four residents reviewed for falls. (Resident 46)

Inspectors wroteBased on record review and interview, the facility failed to complete an Annual MDS (Minimum Data Set) assessment timely for 1 of 16 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide ADL (Activities of Daily Living) services related to nail care and facial hair removal for 1 of 3 residents reviewed for ADL care. (Resident 46)

Inspectors wroteBased on observation, interview and record review, the facility failed to provide activity programs in the evenings. This had the potential to affect 57 out of 57 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the environment was free from accidents and hazards related to medication left unattended on 1 or 2 halls. (200 hall, Resident 7)

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure oxygen tubing and humidifiers were maintained per standards appropriately for 2 of 3 residents observed for respiratory care. (Residents 259 & 36)

Inspectors wroteBased on record review and interview, the facility failed to discontinue or obtain a new order for a PRN (as needed) psychotropic medication after 14 days, for 1 of 5 residents whose medications were reviewed. (Resident 44)

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly notify the ordering physician of laboratory results requiring medical treatment according to policies and procedures for notification and the medical order for 1 of 3 reviewed for antibiotics. (Resident 7)

Inspectors wroteBased on observation and interview, failed to ensure infection control practices were in place for 1 of 1 resident observed during catheter care. (Resident 259)

Inspectors wroteBased on record review and interview, the facility failed to assess a resident's ability to self-administer medication timely for 1 of 1 resident's reviewed for self-administration of medication. (Resident 1)

Inspectors wroteBased on interview, and record review the facility failed to develop a person-centered care plan for 1 of 21 residents whose care plans were reviewed. (Resident 10)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control practices were maintained during wound care for a 1 of 1 residents reviewed. (Resident 30)

Inspectors wroteBased on observation, and interview, the facility failed to ensure medication storage areas were free form loose medications; undated opened medications; and medication with no resident identifiers during medication storage reviews for 1 of 2 medication rooms observed and 1 of 2 medication carts observed. (200 Hall Front Medication cart, 100 Hall medication room and 300 Hall medication room)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control practices were maintained for the cleaning and disinfection of a glucose monitoring machine and durung the administration of a subcutaneous injection for 1 of 1 resident reviewed. (Resident 45)