Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenwood Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia and a history of exit-seeking behavior, who was supposed to be on one-to-one staff supervision, was able to leave a secured memory care unit by exiting through a window, traversing a courtyard, and climbing over a fence. The resident was not under direct supervision at the time due to staff being reassigned to other duties, and was later found approximately two miles from the facility.
A resident with severe cognitive impairment was improperly restrained by a CNA during care, violating the facility's policy on abuse and neglect. The resident became combative, and the CNA held down the resident's arms, which was witnessed by a hospice aide. This action was against the facility's policy, which emphasizes resident-centered care.
The facility failed to provide written notification of transfer and discharge to four residents and/or their representatives, as required. Residents with various medical conditions, including opioid dependence, respiratory failure, and encephalopathy, were transferred to the hospital without the necessary documentation. The DON confirmed the lack of documentation and provided the facility's policy, which requires notification of transfer and discharge rights.
The facility failed to provide written notification of the bed-hold policy to residents or their representatives during hospital transfers. This deficiency affected four residents, including those with conditions such as opioid dependence, respiratory failure, and encephalopathy. The Director of Nursing confirmed the absence of documentation, and the facility's bed-hold policy procedures were not followed.
A resident with ESRD and GERD was observed with Tums at her bedside without a physician's order or a self-administration assessment. The facility's policy requires an assessment by the IDT before self-administration, but the resident's records lacked this documentation, as confirmed by the LPN and DON.
The facility failed to ensure an adequately lit, homelike environment in Unit G, as observed through dim, flickering lights and dark walls lacking decor. Interviews confirmed these conditions, and the Administrator acknowledged the issue. The Residents Rights document indicated residents' right to a comfortable environment with adequate lighting.
Failure to Provide Required Supervision Resulting in Resident Elopement
Penalty
Summary
A resident with diagnoses including dementia, alcohol abuse, and frontotemporal neurocognitive disorder, who resided on a secured memory care unit, was identified as being at risk for elopement and was placed on one-to-one staff supervision due to exit-seeking behaviors. Despite this intervention, the resident was able to exit the facility through a window in another resident's room. The window led to a secured courtyard, from which the resident used a chair to climb over a six-foot privacy fence and subsequently left the premises. The resident was later found by staff approximately two miles from the facility. On the day of the incident, the staff member assigned to provide one-to-one supervision for the resident was reassigned to perform general duties with other residents due to staffing shortages. As a result, the resident did not receive the required one-to-one supervision during the day shift. Multiple staff interviews confirmed that the resident was not under direct observation at the time of the elopement, and some staff were unaware that the supervision had lapsed. The resident had a documented history of exit-seeking behavior, including a previous incident where he left the facility through a window and walked to a grocery store. Observations and interviews revealed that the resident was able to manipulate the window hardware, remove screws, and exit through the window without staff detection. The facility's elopement prevention policy defined elopement as leaving the premises or a safe area without authorization or necessary supervision. The failure to provide the required supervision allowed the resident to leave the secured unit and the facility, resulting in the deficiency cited by surveyors.
Removal Plan
- audits of elopement evaluations and care plans
- inservicing staff on elopement procedures and one-to-one staff supervision
- ongoing monitoring
Resident's Rights Violated by Improper Restraint
Penalty
Summary
The facility failed to protect a resident's rights to be free from physical abuse by a staff member. During an incident, a Certified Nursing Assistant (CNA) held down a resident's arms to provide care. The resident, who had severe cognitive impairment due to Alzheimer's disease, dementia, and anxiety disorder, became combative during care. The CNA restrained the resident's arms to prevent injury to herself, which was considered improper use of restraints according to the facility's policy. The incident was observed by a hospice aide who was present in the room and had initially called the CNA for assistance. The hospice aide reported that the resident was kicking and hitting during the care process, prompting the request for help. Upon entering the room, the CNA forcibly held down the resident's arms and made a comment about the situation leading to bruises. This action was against the facility's policy on abuse and neglect, which emphasizes providing resident-centered care that meets the psychosocial, physical, and emotional needs of the residents.
Failure to Provide Written Notification for Transfer and Discharge
Penalty
Summary
The facility failed to provide the required written notification for transfer and discharge to residents and/or their representatives for four residents who were hospitalized and discharged. Resident 96, diagnosed with opioid dependence and acute respiratory failure with hypoxia, was transferred to the hospital on two occasions, but the clinical record lacked documentation of the Notice of Transfer and Discharge forms. Similarly, Resident 148, with conditions including asthma and dependence on a respirator, was sent to the hospital, yet there was no documentation of the required notification forms. Resident 145, suffering from a pressure ulcer and osteomyelitis, was transferred to the hospital due to worsening of a wound, but the necessary written notification was not documented. Resident 160, diagnosed with encephalopathy, was also transferred to the hospital twice without the required documentation of notification forms. The Director of Nursing confirmed the absence of documentation for all four residents and provided the facility's undated Transfer and Discharge Policy, which mandates that a letter containing admission, discharge, transfer, and appeal rights be discussed and mailed to the resident or responsible party.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to residents or their representatives when residents were transferred to the hospital. This deficiency was identified for four residents who were reviewed for hospitalization and discharge. Resident 96, who had diagnoses including opioid dependence and acute respiratory failure with hypoxia, was transferred to the hospital on two occasions, but there was no documentation of the bed-hold policy being provided. Similarly, Resident 148, with conditions such as asthma and dependence on a respirator, was transferred to the hospital, and the clinical record lacked the necessary documentation of the bed-hold policy notification. Resident 145, who had a pressure ulcer and osteomyelitis, was transferred to the hospital due to worsening of a wound, yet there was no record of the bed-hold policy being communicated. The Director of Nursing confirmed that the policy was not sent with the resident. Resident 160, diagnosed with encephalopathy, was also transferred to the hospital twice, and again, there was no documentation of the bed-hold policy being provided. The Director of Nursing acknowledged the absence of documentation for all four residents. The facility's undated bed-hold policy was reviewed, which outlined procedures for notifying residents or their representatives about bed-hold days used and remaining, but these procedures were not followed in these cases.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was clinically assessed and authorized to self-administer medication. Resident 38, who has diagnoses including end-stage renal disease (ESRD) and gastro-esophageal reflux disease (GERD), was observed multiple times with a bottle of Tums on her bedside table and in her bed. However, her clinical records did not include a physician's order for Tums or an assessment authorizing her to self-administer this medication. The facility's policy requires a self-administration of medication assessment to be completed by the interdisciplinary team before a resident can self-administer medications. Despite this requirement, Resident 38's records lacked a recent assessment for self-administration of Tums, and her care plan did not include provisions for self-administration of medication. Interviews with the LPN and the Director of Nursing confirmed the absence of the necessary assessment and documentation.
Inadequate Lighting and Lack of Homelike Environment in Unit G
Penalty
Summary
The facility failed to provide an adequately lit, homelike environment in the secured Unit G, as observed during multiple dates and times. The main hallway of Unit G was consistently noted to have dim, flickering overhead fluorescent lights and dark-colored walls that lacked homelike decor or adornment. These observations were confirmed through confidential interviews conducted from August 6 to August 12, 2024, which indicated that the lighting conditions were consistently poor. During an interview on August 12, 2024, the Administrator acknowledged the dim lighting and lack of decor in the hallway. The Assistant Director of Nursing provided the Residents Rights and Facility Responsibilities document, which stated that residents have the right to a safe, clean, comfortable, and homelike environment with adequate and comfortable lighting levels in all areas.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Greenwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenwood Health And Living Community | 1.2 mi | ★★★★★ | 5 | 0 |
| Greenwood Meadows | 1.3 mi | ★★★★★ | 4 | 0 |
| University Heights Health And Living Community | 1.4 mi | ★★★★★ | 3 | 0 |
| Greenwood Village South | 2.6 mi | ★★★★★ | 8 | 0 |
| Aspen Trace Health & Living Community | 2.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.