Greenwood Rehabilitation and Healthcare Center

Inspectors wroteBased on observation and interview, the facility failed to ensure a functional, sanitary, environment for residents, staff and the public. Observation of the facility's back 300 Hall revealed water damage to the ceilings, which affected two residents (Resident (R)99 and R106) and had the potential to affect any of the 28 residents residing on the hall.

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1, the facility failed to ensure its Minimum Sata Set (MDS) Assessments accurately reflected the status of 1 of 1 sampled residents, (Resident [R] 8).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident for 1 of 3 residents sampled for accidents/falls, (Resident (R)8).

Inspectors wroteBased on interview, record review and review of facility policy, the facility failed to ensure that 2 of 2 residents reviewed for care plan participation were afforded the opportunity to participate in the development of their care plan (Resident (R)1 and R6).

Inspectors wrote483.25 Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to ensure the safety of its residents for 1 of 5 residents, (Resident (R)8).

Inspectors wrote483.45Based on observation, interview, record review, and facility policy review the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observation of 300 hall medication refrigerator revealed expired medications for 2 residents (Resident (R)19, R115).

Inspectors wrote483.60Based on observation, interview, record review, and review of facility documents and policy, the facility failed to ensure each resident received food that accommodated the resident's allergies, intolerances, and preferences for 4 of 4 residents reviewed for accommodation of preferences (Resident (R)1, R38, R68, R5). [NAME], [NAME] (1) [NAME], [NAME] (27868) - Food No Notes [NAME], [NAME] (1) [NAME], [NAME] (27868) - RESIDENT NOTE No Notes

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to maintain an effective infection prevent program to help prevent the development and transmission of communicable infections for 2 of 7 residents reviewed for infection control (Resident (R)106 and R6). Staff failed to implement Enhanced Barrier Precautions (EBP) by wearing gowns during high contact resident care activities for the two residents, who had clinical indications which required EBP.

Inspectors wrote483.90Based on observation, interview, record review, and facility policy review, the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance through a communication system (call light system) for 2 residents (Resident (R)98, and R117).

Inspectors wroteBased on observation, interview, record and review of facility policy, it was determined the facility failed to implement a comprehensive person-centered care plan for each resident that includes measurable objectives to meet the resident's medical, and nursing needs for two (2) of forty-seven (47) sampled residents (Residents #68 and #75). On 05/19/2022, Resident #75 fell to the floor while ambulating in the hallway, hitting his/her head and was noted to have bleeding above the left eyebrow and, also a tooth was noted to be dislodged. The resident became confused, pupils were assessed as unequal and sluggish, and he/she lost consciousness. The facility transferred the resident to the local hospital Emergency Department (ED) where a Computerized Tomography (CT Scan) was performed with clear results. The resident returned to the facility the same day. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident was provided adequate supervision and assistance devices to prevent falls for one (1) of forty-seven (47) sampled residents (Resident #75). Resident #75 had a history of falls, sustaining eleven (11) falls from 01/17/2022 to 05/18/2022. On 05/19/2022, the resident fell to the floor while ambulating in the hallway, hitting his/her head and was noted to have bleeding above the left eyebrow and, also a tooth was noted to be dislodged. Further, the resident became confused, pupils were assessed as unequal and sluggish, and the resident lost consciousness and was transferred to the local hospital Emergency Department (ED). A Computerized Tomography (CT Scan) was performed at the ED, with clear results. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control (IPC) program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19. Observation, on 06/28/2022, revealed Certified Nursing Assistant (CNA) #2 was working on the 200 Hall and took a rolling vital sign machine into room [ROOM NUMBER]. After using the blood pressure (BP) cuff and pulse oximeter monitor on Resident #85, she failed to clean and disinfect the equipment prior to entering Rooms 218 and room [ROOM NUMBER], and obtaining vital signs and oxygen saturation levels for Residents #21, #34, #57, and #68. [...]

Inspectors wroteBased on observation, interview, record review and review of facility policy, it was determined the facility failed to protect one (1) of forty-seven (47) sampled residents from physical abuse. Resident #75 had a history of wandering and wore a Wanderguard bracelet. Per Patient Care Assistant (PCA)'s #2 documented interview, completed on 02/04/2022 by the former Director of Nursing (DON), Resident #75 was in Resident #64's room, and Resident #64 began yelling at the PCA to get Resident #75 out of his/her room. According to the facility investigation, PCA #2 witnessed Resident #64 touch Resident #75's right shoulder to attempt to guide the resident toward the door. However, after the incident, Resident #75 continued wandering into other residents' rooms and picking up their belongings. On 03/30/2022, Resident #46 struck Resident #75. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure a resident who has an indwelling urinary catheter receives the appropriate treatment and services to prevent urinary tract infections for one (1) of forty-seven (47) sampled residents (Resident #68). Observation on 06/28/2022, revealed Resident 68's indwelling urinary catheter drainage bag was anchored near the head of the bed and not below the bladder.

Inspectors wroteBased on observation, interview, and review of the facility's policy, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation of the kitchen on 06/28/2022, revealed an unopened bag of Salisbury steaks which had not been dated when removed from the original box and placed in the freezer.

Inspectors wroteBased on observation, interview, and review of the Safety Data Sheet for the Super Sani-Cloth Germicidal Wipes, it was determined the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents. Observation on 06/28/2022, revealed a container of Super Sani-Cloth Germicidal Wipes was left unattended on a medication cart on the 200 hall; and there was also a container of Super Sani-Cloth Germicidal Wipes unattended on the 200 hall ledge of the nurses' station, with residents nearby. Additionally, observation on 07/01/2022, revealed a container of Super Sani-Cloth Germicidal Wipes was left unattended on a medication cart on the 200 hall with residents nearby.

Inspectors wroteBased on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure all drugs and biological's were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. Observation of a medication pass revealed Registered Nurse (RN) #1 left a bottle of Flonase Nasal Spray on top of the medication cart in the hallway unattended.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of twenty-eight (28) sampled residents and (1) unsampled resident (Residents #37 and #223). Observation revealed Licensed Practical Nurse (LPN) #1 dropped a glove on the floor and picked it up and used it to administer medications through Resident #37's G-Tube; and, observation of Resident 223's peri care revealed two (2) Certified Nurse Aides (CNAs) failed to wash their hands and change gloves during the care.