Greenridge Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pain was controlled, for one of three sampled residents (Resident 1), when the facility failed to timely administer pain relief medication to Resident 1. A review of Resident 1's admission record (AR), dated 4/11/26, indicated Resident 1 was admitted for HB-SS with acute chest syndrome (sickle cell disease with sickle-shaped red blood cells blocking blood flow in the lungs, leading to inflammation, low oxygen levels and pain, including severe pain). During a record review of Resident 1's minimum data set (MDS, an assessment tool to guide resident care), dated 4/1/26, the MDS indicated Resident 1 had a Brief Interview for Mental Status score of 14 (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of the residents, for one of three sampled residents (Resident 1), when the facility failed to obtain emergency medication to timely administer pain relief medication to Resident 1. A review of Resident 1's admission record (AR), dated 4/11/26, indicated Resident 1 was admitted for HB-SS with acute chest syndrome (sickle cell disease with sickle-shaped red blood cells blocking blood flow in the lungs, leading to inflammation, low oxygen levels and pain, including severe pain). [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) received necessary care and services in accordance with professional standards of practice when Licensed Vocational Nurse (LVN) 1 did not re-assess and/or document Resident 1's vital signs (Vital signs reflect essential body functions, including heartbeat, breathing rate, temperature, and blood pressure and health care providers monitor vital signs to check patients' level of physical functioning) after a change in blood pressure (Blood pressure is the measurement of the pressure or force of blood inside your arteries. Each time heart beats, it pumps blood into arteries that carry blood throughout the body) and oxygen saturation (is the amount of oxygen you have circulating in your blood) values were noted significantly lower from Resident 1's baseline for more than 12 hours. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure kitchen staff were competent in job duties related to testing the sanitization solution concentration in the low temperature dishwasher. This failure has the potential for improper cleaning and sanitization which could lead to increase in risk for food-borne illness for 57 out of 57 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food safely when the low-temperature dishwasher did not have sanitizer running through it on final rinse and when sanitization concentrations were not recorded on the sanitization log. This failure has the potential of placing 56 out of 57 residents at risk for food born illnesses. Findings During a concurrent observation and interview on 1/22/24 at 9:38 a.m., with Dietary Aide (DA1) and Certified Dietary Manager (CDM), in the kitchen, the bottle of chlorine sanitizer connected to the low-temperature dishwasher was empty. CDM stated the kitchen staff need to be checking sanitizer levels every day. CDM also stated that items that were previously washed need to be rewashed in order to prevent contamination. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' rooms were safe, functional, sanitary and comfortable when, - Hot water in the bathrooms in rooms [ROOM NUMBERS] was too hot and - Air vent registers in rooms 29 A, 25 A, 21 A, 20 A, 18 A, 16 A, 10 A, 8 A, and 2 B were covered with thick brownish matter. These failures resulted in resident rooms 4,12, 29 A, 27 A, 25 A, 21 A, 20 A, 18 A, 16 A, 10 A, 8 A and 2 B not being safe, functional, sanitary and comfortable.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food quality and integrity of stored food items when: 1. In the kitchen's dry storage room, there were eight bags of marshmallows dated 8/25/21, three months past the recommended storage guideline of two months. 2. In the kitchen's dry storage room, there were two bags of hotdog buns dated 10/20/21, 14 weeks past the recommended storage guideline of seven days. This failure had the potential to result in the residents being offered less palatable food, which could result in less food intake and weight loss, or potentially developing food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three nursing staff performed required hand hygiene (handwashing or use of an alcohol-based hand sanitizer) for four of 12 sampled residents (Residents 39, 2, 8, and 25) when: 1. The Director of Nursing (DON) failed to perform hand hygiene between doffing soiled gloves and donning new gloves during Resident 39's wound dressing changes for two separate wounds. 2. Licensed Vocational Nurse 1 (LVN 1) failed to perform hand hygiene between doffing soiled gloves and donning new gloves during Resident 2's wound dressing change. 3. Licensed Vocation Nurse 2 (LVN 2) failed to perform hand hygiene before and after direct contact with Resident 8 to administer medication. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff indicated the opened-on date for one of one multidose vial (vial of liquid medication intended for injection/infusion that contains more than one dose) of influenza vaccine. The failure to label the vaccine vial had the potential to result in facility residents receiving an expired, ineffective dose of influenza vaccine which would not provide adequate protection against influenza.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate dispensing and accounting of emergency medications when the intravenous (IV - administered through vein) emergency kit (IV E-Kit) was not replaced after it was opened and used items was not accounted. This deficient practice placed residents at risk for not receiving the necessary IV supplies in an emergency.

Inspectors wroteBased on observation and interview, the facility failed to prepare, store, and serve food under sanitary conditions when dirty ladles, plates, tong and drawer were stored in the same drawer with clean utensils. These failures placed residents at risk for contracting food borne illness.