Greenwood Center for Rehabilitation and Nursing

Inspectors wroteBased on clinical record review and resident and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan related to risk for falls for one of three residents reviewed (Resident 1).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, comfortable, homelike environment for two of six Residents (Residents 1 and 3).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice, regarding physician ordered medications, for one of four residents reviewed (Resident 3). Findings Include: Review of Resident 3's clinical record revealed diagnoses that included Rheumatoid Arthritis (RA-a chronic autoimmune disorder causing immune system-driven inflammation, primarily leading to painful, stiff, and swollen joints) and Type 2 Diabetes Mellitus (when the body cannot use insulin correctly and sugar builds up in the blood). Review of Resident 3's current physician orders revealed an order, dated December 1, 2025, for Humira (medication used to treat RA) 40mg/0.4ml (milligrams/milliliter), inject one application every 14 days for RA. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to notify a resident's representative of a new medication order for one of four residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Change in a Resident's Condition or Status, revised May 2017, revealed, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Review of Resident 1's clinical record revealed diagnoses that included hypertension (high blood pressure) and Type 2 Diabetes Mellitus (when the body cannot use insulin correctly and sugar builds up in the blood). Review of Resident 1's physician note dated March 30, 2026, revealed that Resident 1 presented with a painful rash to her right buttocks. [...]

Inspectors wroteBased on review of select facility policy and procedures, observation, and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the main kitchen (Main Kitchen of Facility) and maintain equipment in a safe and sanitary condition on one of five nursing units reviewed (400 Nursing Unit).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medications for one of 27 sampled residents, and skin integrity for one of 27 sampled residents (Residents 38 and 122).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to offer COVID-19 immunizations to ensure residents were up to date with the most current available immunization for five of five residents reviewed (Residents 1, 2, 3, 6, and 9), failed to maintain documentation of staff COVID-19 vaccination status, and provide evidence that staff were offered the COVID-19 vaccine or information on obtaining the COVID-19 vaccine.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to ensure residents' rights to secure and confidential personal and medical information in the lobby area of the facility and for one of one resident reviewed for privacy concerns (Facility Main Lobby Area; Resident 12).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping services to ensure a clean, safe, and orderly environment on one of five nursing units (Medication and Medical Supply Area located on the 400 Nursing Unit).

Inspectors wroteBased on clinical record review, and resident and staff interview, it was determined that the facility failed to ensure that a resident received proper treatment for vision services for one of two residents reviewed for vision concerns (Resident 9).

Inspectors wroteBased on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to arrange for the necessary foot care for one of 27 residents reviewed (Resident 122).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of six residents reviewed for mood/behavior (Resident 4).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of three residents reviewed (Residents 4).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (100 Nursing Unit; Residents 21 and 46).

Inspectors wroteBased on clinical record review, and resident and staff interview, it was determined that the facility failed to obtain dental services for one of nine residents reviewed for dental concerns (Resident 122).

Inspectors wroteBased on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to obtain professional dental services for three of nine residents reviewed for dental concerns (Residents 9, 28, and 125).

Inspectors wroteBased on a review of facility procedures, observation, and resident and staff interview, the facility failed to follow proper infection prevention practices for foot care equipment for two of 27 residents reviewed (Residents 29 and 48).

Inspectors wroteThe facility failed to store and prepare food in accordance with professional standards for food safety in the main kitchen and on one of three nursing units (100/300 solarium pantry).

Inspectors wroteBased on observation and resident and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on three of five nursing halls (100, 200, and 400 Nursing Halls, Residents 16, 42, 91, and 101).

Inspectors wroteBased on staff interview it was determined the facility failed to employ qualified activity personnel to oversee the facility's activity program (Employee 6)

Inspectors wroteBased on clinical record review and resident and staff interview, it was determined that the facility failed to ensure routine prophylactic dental services for three of six residents reviewed for dental concerns (Residents 10, 39, and 109).

Inspectors wroteBased on clinical record review and family and staff interview, it was determined that the facility failed to provide a personal funds quarterly statement for one of one resident reviewed for personal funds concerns (Resident 25).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to involve a resident in establishing advance directives for one of 32 residents reviewed (Resident 93).

Inspectors wroteBased on clinical record review, review of select policies and procedures, and staff and resident interview, it was determined that the facility failed to thoroughly investigate and notify the appropriate agencies of an identified incident of potential resident misappropriation of property (money) for one of two residents reviewed for abuse concerns (Resident 36).

Inspectors wroteBased on a review of select facility policies and procedures, a review of select personnel records, and staff interview, it was determined that the facility failed to complete required background check screening for one of five newly hired employees reviewed (Employee 3)

Inspectors wroteBased on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide personal and oral hygiene assistance for dependent residents for three of three residents reviewed for activities of daily living (ADL) concerns (Residents 110, 36, and 93).

Inspectors wroteBased on family and staff interview, and review of facility documents, it was determined that the facility failed to provide an ongoing program of activities designed to meet the individual needs and interests for one of three residents reviewed (Resident 101).

Inspectors wroteBased on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered interventions and treatments for one of 24 residents (Resident 42); and regarding an implanted cardiac pacemaker for one of 24 residents reviewed (Resident 30).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to implement interventions to prevent future falls or accidents for two of three residents reviewed for falls (Residents 93 and 110).

Inspectors wroteBased on closed clinical record review, select facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure that intravenous catheters were assess and maintained per the resident plan of care for one of one resident reviewed (Resident 120).

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of one resident reviewed (Resident 42).

Inspectors wroteBased on a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to thoroughly assess the potential entrapment risks from the use of bed rails for one of five residents reviewed for accident hazards (Resident 10).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by two of three residents reviewed (Residents 39 and 99).

Inspectors wroteBased on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement enhanced barrier precautions for one of two residents reviewed for infection control concerns (Resident 173).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to notify the State Ombudsman of a transfer to the hospital with the required information for three of six residents reviewed (Residents 77, 93, and 110).

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to provide the highest practicable care regarding physician ordered diagnostic testing for one of three residents reviewed (Resident CR1) and physician ordered medications that resulted in hospitalization for one of three residents reviewed resulting in harm (renal failure and digoxin toxicity) (Resident 1).

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to provide bathing assistance for a dependent resident for one of six residents reviewed (Resident 1).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered vital signs for one of six residents reviewed (Resident 1).

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to store food to prevent the potential spread of food borne illness and maintain food service/storage equipment in a sanitary manner in the facility's main kitchen and one of three dining areas nursing units (100/300 dining room).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for three of six residents reviewed for hospitalizations (Residents 41, 75, and 221).

Inspectors wroteBased on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide bathing assistance for residents dependent on staff assistance for five of six residents sampled for activities of daily living (Residents 52, 60, 64 and 96), and the facility failed to provide a resident with transfer assistance out of bed for a resident dependent on staff assistance, for one of six residents sampled. (Resident 92).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by four of four residents reviewed (Residents 17, 43, 44, 94).

Inspectors wroteBased on review of select policies and staff interview, it was determined that the facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia).

Inspectors wroteBased on review of facility staff education records and staff interview, it was determined that the facility failed to ensure that all nurse aide staff completed a minimum of 12 hours of in-service education training each year for three of three nurse aides reviewed (Employees 1, 2, and 3).

Inspectors wroteBased on review of select facility policies and procedures, review of employee personnel records, observation, and staff interview, it was determined that the facility failed to investigate a resident's injuries of unknown origin for one of 25 residents sampled (Resident 75) and failed to implement its abuse prohibition policy pertaining to screening for one of five newly hired employees reviewed (Employee 1).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 25 residents reviewed (Resident 110).

Inspectors wroteBased on clinical record review and resident and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for one of one resident reviewed (Residents 50). Findings Include: Clinical record review for Resident 50 revealed a psychiatry note dated [DATE], that indicated she wanted to die so she can be with her babies. The note indicated that she did not have a plan and that she stated she would never harm herself. Further review of the psychiatry note revealed that Resident 50 indicated that she mourns her son's death. She stated he died one- and one-half days after he was born, and she never got to hold him. [...]

Inspectors wroteBased on clinical record review and family and staff interview, it was determined that the facility failed to promote resident and/or responsible party involvement with care plan development for one of one resident reviewed (Resident 101).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion for one of 5 residents reviewed (Resident 44).

Inspectors wroteBased on observation, review of select facility policies, facility documents, clinical record review, and staff and resident interview, it was determined that the facility failed to implement appropriate interventions to prevent falls for one of five residents reviewed for falls (Resident 52).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to assess and implement individualized interventions to promote bowel and bladder continence for one of two residents reviewed for incontinence (Resident 115).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for one of six residents reviewed (Resident 42).

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of three residents reviewed (Resident 75).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for one of four residents reviewed (Resident 91).

Inspectors wroteBased on clinical record review, observations, and staff and resident interview, it was determined that the facility failed to ensure the availability of necessary emergency supplies for two out of three residents reviewed receiving hemodialysis (Residents 70 and 90).

Inspectors wroteBased on clinical record review and resident and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care and eliminate or mitigate re-traumatization for one of one resident reviewed (Resident 50).

Inspectors wroteBased on observation, clinical record review, and staff and family interview, it was determined that the facility failed to assess for the risk of side rail entrapment, for three of five residents reviewed for side rails (Residents 74, 104, and 105).

Inspectors wroteBased on review of facility documentation and staff interviews, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with enteral tube feeding, catheter care, medication administration, and dressing changes for two of six employee competencies reviewed (Employees 11 and 12).

Inspectors wroteBased on clinical record review and staff and responsible party interview, it was determined that the facility failed to monitor antibiotic use for one of one resident reviewed for a urinary tract infection (Resident 74).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure a resident received or was offered pneumococcal conjugate vaccines for one of five residents reviewed for immunization concerns (Resident 4).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital for four of six residents reviewed (Residents 41, 60, 75, and 221).

Inspectors wroteBased on review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection for one of six residents reviewed (Resident 1).