Greenville Health and Rehabilitation Center

Inspectors wroteBased on record review and interviews with staff, Physicians and Nurse Practitioners (NP), the facility failed to notify and consult with a medical provider for new onset and continued vomiting and when bolus tube feedings (liquid formula is administered through a feeding tube into the stomach in larger volumes over a short period) were held for a severely cognitively impaired resident with a diagnosis of traumatic brain injury (disruption in normal brain function caused by an external mechanical force) who received all fluid and caloric intake through tube feedings. Resident #145 had an acute vomiting episode on [DATE] (Friday) before 6:00 AM, and the 6:00 AM bolus feeding was held. The medical provider was not notified of the vomiting or that the bolus tube feeding was being held. [...]

Inspectors wroteBased on record review and interviews with staff, Physicians and Nurse Practitioners (NP), the facility failed to identify the seriousness of new onset and continued vomiting, complete and document ongoing comprehensive nursing assessments of the residents condition or identify the urgent need for medical attention for a severely cognitively impaired resident with a diagnosis of traumatic brain injury who received all fluid and caloric intake through bolus tube feedings six times a day. Resident #145 had an acute vomiting episode on [DATE] and the 6:00 AM bolus feeding was held. Nursing staff provided three scheduled bolus tube feedings on [DATE] before the 10:00 PM bolus tube feeding was held due to vomiting. The on- call provider was contacted and notified Resident #145's abdominal area had hypoactive bowel sounds and was distended/bloated. [...]

Inspectors wroteBased on record review, observation, staff, Nurse Practitioner, Respiratory Therapist and Medical Director interviews, the facility failed to reconcile conflicting information regarding the resident's oxygen flow rate following readmission from the hospital, for 1 of 3 residents reviewed for respiratory services (Resident #32).

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to maintain an accurate medical record for the administration of supplemental oxygen for 1 of 3 residents reviewed for respiratory services (Resident #32). Resident #32 was readmitted to the facility on [DATE]. Review of a physician order dated 7/6/2026, showed an active order for humidified oxygen to tracheostomy: 3 liters (L) every shift for tracheostomy use. Review of Medication Administration Record (MAR) dated July 2026 showed a physician order entered 7/6/2026 for humidified oxygen to trach: 3 liters (L) every shift for tracheostomy use. The MAR documented the order was signed as administered by Nurse #6 for the dayshift on 7/15/2026. On 7/15/2026 at 2:05 pm, Nurse #6, assisted by the Assistant Director of Nursing (ADON), was observed performing tracheostomy care on Resident #32. [...]

Inspectors wrote2. Resident #85 was re-admitted to the facility on [DATE] with a diagnosis of cerebral infarction (disrupted blood supply to the brain). A review of his admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. He had functional limitation in range of motion on both sides of his upper and lower extremities. He required substantial/maximal assistance to roll left and right in bed. Resident #85 was always incontinent of bladder. He had no falls since his re-entry to the facility. On 6/2/25 at 3:37 PM a review of an unsigned incident report provided by the Director of Nursing (DON) dated 10/9/24 at 7:12 PM revealed at 3:30 PM on 10/9/24 staff was assisting Resident #85 with incontinence care, Resident #85 rolled out of bed face down sustaining a small skin tear on his forehead. [...]

Inspectors wroteBased on observation and interviews with staff, the facility failed to secure a packaged terminal air conditioner (PTAC) unit to the wall on 1 of 5 resident halls reviewed for the environment (Resident #280's room).

Inspectors wroteBased on record review and staff interviews, the facility failed to file a grievance on behalf of a resident when the resident reported a grievance verbally to the Social Worker (SW) related to multiple items missing from her belongings after returning from a short hospital stay. The missing items were not located. This deficient practice affected 1 of 1 resident reviewed for grievances Resident #93).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of high risk drug class medications. This was for 1 of 5 residents reviewed for unnecessary medications (Resident #30).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to develop a comprehensive care plan for a resident in the areas of bed rails (Resident #94) and for the use of a Continuous Positive Airway Pressure (CPAP) machine for one resident (Resident #63). This was for 2 of 24 residents reviewed for comprehensive care plans.

Inspectors wroteBased on observation, record review, and staff and Wound Care Nurse Practitioner (NP) interviews, the facility failed to obtain a provider order for and implement the recommended pressure relief measure of a heel protection boot for 1 of 1 resident reviewed for a non-pressure related heel wound (Resident #62).

Inspectors wroteBased on observations, record review, and staff and Nurse Practitioner interviews, the facility failed to ensure infection control standards were followed when Nurse #8 did not remove soiled gloves, perform hand hygiene, and don sterile gloves during tracheostomy (a surgically created opening in the windpipe through the neck to provide an airway for breathing) care for a resident and also failed to change the tracheostomy ties per the Physician's order (Resident #33). In addition, the facility failed to obtain a Physician's order for the use of a Continuous Positive Airway Pressure (CPAP) machine for one resident (Resident #63). This deficient practice affected 2 of 2 residents reviewed for respiratory care (Resident #33 and Resident #63).

Inspectors wroteBased on observations, record review and staff interviews the facility failed to attempt alternative interventions, assess for entrapment risk, review the risks and benefits of the use of side rails, and/or obtain consent from the resident or resident representative prior to installing bilateral quarter length side rails (Resident #94 and Resident #172). In addition, the facility failed to attempt alternative interventions prior to installing bilateral quarter length side rails (Resident #63). This deficient practice affected 3 of 3 residents reviewed for side rails (Resident #94, Resident #172, and Resident #63).

Inspectors wroteBased on record review and staff interviews, the facility failed to document the completion of wound treatments provided to a resident. This was for 1 of 3 residents (Resident #85) reviewed for pressure ulcers.

Inspectors wroteBased on observation, record review, and staff and Nurse Practitioner(NP) interviews, the facility failed to ensure infection control standards were followed when Nurse #3 dropped a residents medication on the top of the medication cart, picked it up with her bare fingers, placed it in the medication cup and gave the medications to the resident. This was for 1 of 11 staff members reviewed for infection control practices (Nurse #3).

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain documentation of grievances and evidence of the result of all grievances for 7 of 7 months reviewed.

Inspectors wroteBased on record review, and staff interviews and Pharmacist interviews, the facility failed to provide care according to professional standards when Nurse #1 borrowed medication from Resident #6 to administer to Resident #5.

Inspectors wroteBased on record review and staff interviews, the facility failed to have a complete and accurate Medication Administration Record (MAR) for 1 of 3 residents (Resident #11) reviewed for record accuracy.

Inspectors wroteBased on record review and interviews with facility staff and the Nurse Practitioner (NP), the facility failed to ensure there was effective communication during shift to shift report between facility nursing staff to avoid a lapse between the time Resident #1's STAT (immediately) lab was obtained to when the results for a STAT complete blood count (CBC) were received resulting in failure to identify critically low laboratory results. This deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for quality of care.

Inspectors wroteBased on record review and interviews with facility staff, Nurse Practitioner (NP), and the facility's contracted laboratory company, the facility failed to ensure there was effective communication between facility staff and the lab company to avoid a lapse of multiple days between the time Resident #1's STAT (immediately) lab was obtained to when the results for a STAT complete blood count (CBC) were received resulting in failure to identify critically low laboratory results timely. This deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for laboratory services.

Inspectors wroteBased on observations, staff, Podiatrist, and resident interviews and record review the facility failed to ensure a resident was free from injury while being loaded into the transportation van for 1 of 6 residents reviewed for accidents. Resident #72's right foot became caught between the van ramp and hydraulic lift platform and she sustained an avulsion to her right great toe (forcible tearing off of skin), the skin was unable to be sewn together, x-ray results showed the toe had a minimally displaced fracture (Resident #72).

Inspectors wroteBased on record review and staff interviews the facility failed to have a documented water management program for Legionella. The facility further failed to ensure hand hygiene was performed during medication administration for 1 of 2 nurses observed (Nurse #1).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to remove an open and expired medication from 1 of 2 medication storage rooms observed (Hall 300/400) and failed to ensure 1 of 5 medication carts (Hall 300) and 1 of 1 wound treatment carts were secured while unattended.

Inspectors wroteBased on records review, and staff interviews, the facility failed clarify code status in the residents' record for 1 (Resident #59) of 23 residents reviewed for Advance Directives.

Inspectors wroteBased on record review and staff and Nurse Practitioner interviews the facility failed to protect a cognitively intact resident from verbal abuse by another cognitively intact resident that escalated into physical abuse when Resident #216 called Resident #51 a fat b**** and Resident #51 proceeded to purposefully run into Resident #216 with her electric motorized wheelchair (WC) resulting in an abrasion and bruising to Resident #216's right leg. This was for 2 of 4 residents reviewed for abuse.

Inspectors wroteBased on staff, nurse practitioner, and resident interviews and record review the facility failed to protect a resident's right to be free from misappropriation of a narcotic medication (oxycodone) for 2 of 2 residents reviewed for misappropriation of property. (Resident #84, Resident #72)

Inspectors wroteBased on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of medications and diagnoses. This was for 2 of 5 residents reviewed for unnecessary medication (Resident #98 and Resident #262).

Inspectors wroteBased on record review and staff interviews the facility failed to develop the comprehensive care plan in the area of anticoagulant (blood thinning) medication for 1 of 5 residents (Resident #98) reviewed for unnecessary medications.

Inspectors wroteBased on record review, resident, family and staff interviews, the facility failed to ensure residents rights and invite residents/resident representatives to participate in care plan meetings 3 of 7 residents reviewed for care plan meetings (Residents #31, Resident #53 and Resident #362).

Inspectors wroteBased on observation, record review, staff interviews, and Pharmacist interview, the facility failed to maintain a medication error rate of less than 5%. Two (2) medication errors were observed out of 25 opportunities which resulted in a medication error rate of 8%. This occurred for 1 of 3 residents reviewed during a medication pass observation (Resident #7).