Greenspring Village

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to implement interventions to prevent the development of a pressure ulcer for one resident, Resident #1 (R1) of 33 residents in the survey sample, which resulted in a facility acquired wound that was identified at the advanced stage 3, constituting harm.

Inspectors wroteBased on resident interview, staff interview and facility documentation review, the facility staff failed to ensure that five residents, (Resident #4 (R4), Resident #8 (R8), Resident #22 (R22), Resident #30 (R30), and Resident #309 (R309)), had the information on how to file a complaint with the state licensure office and state survey agency in a survey sample of 33 residents.

Inspectors wroteBased on observation, resident interviews, staff interviews and facility documentation, the facility staff failed to ensure that five residents,( Resident #4 (R4), Resident #8 (R8), Resident #22 (R22), Resident #30 (R30) and Resident #309 (R309), had the information on how to file a grievance out of a survey of 33 residents.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to implement their abuse policy with regards to the pre-screening of employees for 12 of 25 (Staff C, E, G, H, I, K, M, P, S, U, W, and X) employee/staff records reviewed.

Inspectors wrote3. For Resident #9 (R9), the facility staff failed to respond to a medication regime review (MRR) and recommendation from the pharmacist in a timely manner and failed to give rationale for the decisions selected. On 3/5/25 at 9 a.m., a clinical record review was conducted of R9's chart. This review revealed one MRR dated 12/20/24. This review noted that R9 was on an opioid Tramadol Hydrochloride in combination with a medication that may increase adverse effects, Quetiapine Fumarate. Recommendation: Please consider avoiding or minimizing concomitant use, perhaps tapering Quetiapine. The physician noted, I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: which was blank and gave no rationale. [...]

Inspectors wrote3. For Resident #9 (R9), who was receiving multiple psychotropic medications, the facility staff failed to perform gradual dose reductions and ensure the resident was free from unnecessary psychotropic medications. On 3/4/25 and 3/5/25, R9 was observed attending group activities and eating meals in the dining room. R9 was noted to be calm, engaged and no behaviors noted. On 3/5/25, a clinical record review was conducted. This review revealed that R9 was admitted to the facility on [DATE] from assisted living, where her spouse was also a resident. R9's diagnosis included, but were not limited to: unspecified dementia, unspecified severity, without behaviors/psych/mood/anxiety; bipolar disorder, unspecified; psychotic disorder with delusions due to known physiological condition; unspecified dementia with behavioral disturbance; major depressive disorder, recurrent, mild; [...]

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to prepare food in a sanitary manner in the main kitchen.

Inspectors wroteBased on observation, staff interviews and clinical record review, the facility's quality assessment and assurance program failed to implement appropriate plans of action to correct identified quality deficiencies previously cited, having the potential to affect residents on two of the two nursing units.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to maintain the walk-in freezer in proper working order. The seal on the freezer door was in disrepair and had been in this condition for over seven months.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to protect a resident's right to be free from physical/verbal abuse by a private duty aide for one of thirty-three residents in the survey sample (Resident #252).

Inspectors wroteBased on staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure residents were free from unnecessary psychotropic medications and perform gradual dose reductions for one resident, Resident #111 (R111), out of a survey sample of 11 residents.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide written notification of reasons for transfer or discharge to the resident and the resident's representative(s) for one of thirty-three sampled residents, (Resident #20).

Inspectors wroteBased on observations, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement a timely and adequate baseline care plan for one resident (Resident #49) in a survey sample of 33 residents, that includes the instructions needed to provide effective and person-centered care. On 3/4/25 at 9:50 am, Resident #49 (R49) was observed sitting in a wheelchair beside his bed, wearing a large black molded plastic boot that encased his left foot, from the toes to just below the knee. Also present was R49's significant other/POA. When asked about care satisfaction, R49 nodded his head and looked at his significant other who replied, Yes, I believe that they do a good job here, much better than where he's been before . but I know one thing that they could do better. [...]

Inspectors wroteBased on observations, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement an accurate comprehensive person-centered care plan for one resident (Resident R49) in a survey sample of 33 residents, that included measurable objectives and timeframes. On 3/4/25 at 9:50 am, resident was observed sitting in a wheelchair beside his bed, wearing a large black molded plastic boot that encased his left foot, from the toes to just below the knee. Also present was R49's significant other/POA. When asked about care satisfaction, R49 nodded his head and looked at his significant other who replied, Yes, I believe that they do a good job here, much better than where he's been before . but I know one thing that they could do better. They really need to make sure everyone knows how to fasten his boot properly. [...]

Inspectors wroteBased on observations, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for three residents (Resident #5- R5, Resident #39-R39, and Resident #49-R49), in a survey sample of 33 residents.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to follow professional standards of nursing practice for one resident, Resident #104 (R104), out of a survey sample of 11 residents.

Inspectors wroteBased on resident interviews, staff interviews, clinical record review and facility documentation review, the facility staff failed to assess resident, communicate with the provider, and ensure quality of care for one resident, R#104 (R104), out of a survey sample of 11 residents.

Inspectors wroteBased on staff interviews, clinical record review and facility documentation review, the facility staff failed to implement interventions to prevent accidents from falls for one resident, Resident #106 (R106) out of a survey of 11 residents.

Inspectors wroteBased on observation, resident and family interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to implement nutritional interventions to maintain the resident's nutritional status and weight, for one resident (Resident #101- R101) in a survey sample of eleven residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure appropriate dementia care was in place for one resident (Resident #9-R9), in a survey sample of 33 residents.

Inspectors wroteBased on resident interviews, staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure medication was available for one resident, Resident #104 (R104) out of a survey of 11 residents.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure a medication error rate of less than 5 percent. There were three errors in 29 opportunities resulting in a medication error rate of 10.3%.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for two residents (Resident #108 and Resident #101), in a survey sample of 11 residents.

Inspectors wrote2. During medication administration, the nurse (licensed practical nurse #4- LPN #4) failed to follow standard infection control practices by not wearing gloves, touching multiple surfaces with contaminated the gloves, and then directly handling the medications with contaminated gloves. On 5/14/25 at 8:31 a.m., LPN #4 was observed to prepare and administer medications to a resident on the 200 unit. LPN #4 donned gloves and with her gloved hands took a set of keys from her pocket, opened the medication cabinet located in the resident's room, removed the medication package cards, and returned to the medication cart, touching the medication cart, computer, computer mouse, etc. LPN #4 was then observed removing/popping medications from the package cards directly into her gloved hands and then placed the pills into a medication cup, which were then administered to the resident. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for (1) one of (5) five sampled residents reviewed for immunizations (Resident #1).

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to offer updated COVID-19 vaccines for (1) one of (5) five sampled residents reviewed for immunizations (Resident #15).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a Level I PASRR (preadmission screening and resident review) was completed prior to admission for one of 23 residents, Resident #50.

Inspectors wroteBased on staff interview, and clinical record review, the facility failed to review and revise a care plan regarding safety/wandering for for one of 23 residents in the survey sample, Resident #19. The Findings Include: Resident #19 was admitted to the facility on [DATE]. Diagnoses for Resident #19 included; Respiratory failure, and muscle weakness, and chronic kidney disease. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/31/21. Resident #19 was assessed with long and short-term memory problems and severely cognitively impaired. On 10/6/21 Resident #19's current MDS Section E. behaviors, documented a behavior of wandering occurring 4 to 6 days during the MDS look back period. Resident #19's current care plan for Safety and Exploring was then reviewed and documented no wandering throughout the house or community. [...]

Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to follow physician's orders for bladder scan monitoring and fluid intake for one of 23 residents in the survey sample, Resident #26.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure expired medications were not readily available for distribution on one of 3 units, the 200 unit.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review the facility staff failed to assess seven of twenty residents for bed rail safety (Residents # 12, 16, 48, 39, 65, 66, and 42).

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure regular bed inspection of bed frames, mattresses and bed rails for 7 of 79 beds currently with bed rails in use during the survey (Residents # 12, 16, 48, 39, 65, 66, and 42).

Inspectors wroteBased on clinical record review and staff interview, the facility failed, for one of 18 residents in the survey sample, to notify the local Ombudsman of a resident's transfer to the hospital.

Inspectors wroteBased on observation, staff interview, and clinical record review, facility staff failed to review and revise comprehensive care plans (CCP) for two of 20 residents in the survey sample, Residents #42 and #39. Neither resident's care plans were reviewed by a complete interdisciplinary team (IDT). Resident #42's care plan did not include fall interventions, or use of siderails. Resident #39's care plan did not include interventions for weight loss.

Inspectors wroteBased on observation, facility document review and staff interview, the facility staff failed to ensure expired medications and biologicals were not available for use in one of two medications rooms (Evergreen 2nd floor).