Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Provide Dignified Dining Assistance: Dependent residents seated together in the dining room were repeatedly left with meals in front of them while tablemates were being fed. Staff did not assist residents at the same time, resulting in one resident waiting 15 minutes on one occasion, another falling asleep at the table with breakfast in front of him/her, and other dependent residents waiting 7 to 11 minutes for help. CNAs, an Activities Assistant, and the DON all stated residents sitting at the same table should be assisted at the same time.
Staff failed to maintain sanitary conditions during meal service by not performing hand hygiene between assisting residents and by touching straws where residents’ mouths would touch. An Activities Assistant alternated feeding two residents without washing hands, left to help other residents and handle items such as a phone and pillow without hand hygiene, and staff were observed setting up trays and touching multiple residents’ straws with bare hands before residents drank from them. Interviews confirmed staff should wash hands before meal assistance and between residents.
Failure to Document Pneumococcal Immunizations: The facility failed to document pneumococcal vaccine details in the medical record for 4 of 5 sampled residents age [AGE] and older. Records lacked the vaccine date, name, lot number, and expiration date, even though two residents were listed as current on admission and two HCPs said the vaccines were current. The IP/DON said she relied on families or responsible parties for documentation, did not contact community HCPs, and could not access MIIS because her access had expired.
Failure to Follow Physician Order for Geri Sleeves: A resident with severe cognitive impairment and total dependence for ADLs had a physician order for Geri Sleeves to be applied to both upper extremities every shift, but surveyors repeatedly observed the resident in a wheelchair without the sleeves. The Kardex did not reflect the order, staff gave conflicting statements about whether the resident needed the sleeves, and the DON stated the sleeves were ordered to protect the resident’s frail skin and purpura.
A resident with a history of aspiration pneumonia and dementia was supposed to receive supervision and assistance with eating, but staff repeatedly left the resident to eat alone in the room. Observations showed the resident coughing, struggling to feed self, and having difficulty lifting drinks and finding utensils, while the CNA care card did not match the care plan. The resident and family reported that staff often walked away before the meal was finished, despite the resident needing help and encouragement.
Failure to Obtain Order for Pressure Ulcer Treatment: A resident with Parkinson’s disease, dementia, severe cognitive impairment, and high pressure-ulcer risk developed a new stage 2 wound on the right buttock, but staff used zinc oxide without a physician order. Records showed the wound was documented, yet the TAR/MAR did not reflect treatment, weekly skin checks missed the area, and interviews showed nurses, the wound nurse, DON, NP, and MD were not aligned on who notified the provider or obtained the order.
Missing Padded Side Rail for Resident with Fragile Skin: A resident with dementia, severe cognitive impairment, and fragile arm skin was observed in bed multiple times with the right side rail in place but without the ordered padding. Staff stated the resident flails his/her arms and needs the pad to protect the skin, and bruises and a scab were observed on the resident's arms. The DON confirmed the pad should have been in place as ordered, and the facility had no policy regarding padded side rails.
Inaccurate documentation of Geri Sleeve use: Staff documented that a resident was wearing Geri Sleeves when observations showed the sleeves were not in place. The resident had Alzheimer's disease, dementia, severe cognitive impairment, and was totally dependent for ADLs. The physician's order required Geri Sleeves to both upper extremities every shift, but the Kardex did not reflect the intervention, the record lacked documentation of removal, and the TRS was signed off as if the sleeves were worn. CNAs and the DON confirmed the resident was not wearing them and that staff should not document use when they were absent.
Failure to Provide Dignified Dining Assistance
Penalty
Summary
The facility failed to provide a dignified dining experience for residents in the main dining room by not ensuring dependent residents were fed at the same time while seated together. The facility policy on Residents' Rights stated residents have the right to be treated with dignity and respect, and the policy on Supervision of Resident Nutrition stated residents needing assistance in eating must be promptly assisted upon being served. During observations, dependent residents seated at the same table were repeatedly left with trays in front of them while tablemates were being assisted. On 8/5/25, one dependent resident sat unable to eat while staff assisted the first resident at the table, and the second resident was not assisted until 15 minutes later. On 8/6/25, a dependent resident at a table with two independent residents began falling asleep with breakfast in front of him/her before staff assisted 12 minutes after the meal was served. Also on 8/6/25, two dependent residents at one table received trays at the same time, but one waited seven minutes for assistance while the other was being fed. Later that day, two dependent residents at another table received meals, but one was not assisted until 11 minutes after the tablemate began eating. On 8/7/25, two dependent residents seated together received meals, and one did not receive assistance until seven minutes after the other. Staff interviews confirmed that residents sitting at the same table should be fed at the same time, and the DON stated all residents deserve a dignified dining experience and should be fed at the same time as tablemates when sitting together.
Failure to Maintain Hand Hygiene During Meal Assistance
Penalty
Summary
The facility failed to ensure staff members served meals to residents in the dining room under sanitary conditions with acceptable hand hygiene practices. The facility policies reviewed indicated that staff should wash hands during feeding and after resident contact, including when leaving a resident’s side. During lunch on 8/5/25, an Activities Assistant sat between two residents and alternated feeding them without performing hand hygiene between residents. The same staff member left the table to assist another resident with positioning and to retrieve a pillow with bare hands, then returned to continue feeding the original two residents without hand hygiene. Later that meal, the Activities Assistant left those residents to help another resident with feeding and did not perform hand hygiene before doing so. Additional observations showed staff touching residents’ straws with bare hands where the residents’ mouths would touch the straw during breakfast and lunch services on 8/6/25 and breakfast service on 8/7/25. During lunch on 8/6/25, the Activities Assistant again alternated feeding two residents without hand hygiene between residents, assisted another resident with cutting food using the resident’s utensils, picked up a ringing telephone with bare hands, and left to get ice cream before resuming feeding, all without hand hygiene. Interviews with the Housekeeping Manager, CNA #3, CNA #2, the Activities Assistant, and the DON confirmed that staff should perform hand hygiene before assisting with meals and between residents, should not touch straws where residents’ mouths will touch, and should not feed two residents at the same time.
Failure to Document Pneumococcal Immunizations
Penalty
Summary
The facility failed to document in the medical record that 4 of 5 sampled residents age [AGE] years and older had received pneumococcal immunizations. Record review showed that the facility did not document when the residents received the pneumococcal vaccine, the vaccine name, the lot number, or the expiration date. Two residents were noted as having pneumonia vaccines current on admission, and two residents had health care proxies who indicated the vaccines were current on admission, but the medical record contained no information identifying the type of vaccine or the date it was administered. The facility policy titled "Pneumonia immunization policy" stated that licensed staff would review immunization consent forms and educational materials, check for allergies, administer vaccine as ordered, and document on the MAR, in nursing notes, and on the immunization form the resident's vital signs, vaccine name, lot number, expiration date, injection site, resident response, education, and any declination. During interview, the IP/DON stated she had checked the immunization report sheet dated 10/2024 indicating the 4 residents had received pneumonia vaccines, but she did not have actual dates, vaccine name, lot number, or expiration date documented in the immunization record. She also stated she relied on residents' families or responsible parties to provide the documentation at admission, did not contact community HCPs for the information, and could not access the MIIS because her access had expired.
Failure to Follow Physician Order for Geri Sleeves
Penalty
Summary
The facility failed to implement a physician’s order for Geri Sleeves for one resident. Resident #14, who was admitted in December 2023 with diagnoses including Alzheimer’s disease and dementia, had a most recent MDS showing a BIMS score of 3 out of 15, indicating severe cognitive impairment, and was totally dependent on staff for all activities of daily living. A physician’s order dated 2/27/25 directed staff to apply Geri Sleeves to both upper extremities every shift, with removal allowed for morning and evening care and toileting after meals. Survey observations on multiple days showed Resident #14 sitting in a wheelchair in the dining room with forearms visible and no Geri Sleeves being worn. The resident was observed without the sleeves during morning, midday, and later dining room observations. The resident’s Kardex did not indicate Geri Sleeve use, and the pressure ulcer care plan included a handwritten intervention to apply Geri Sleeves every shift. The medical record did not document any instance of the resident removing the sleeves. During interviews, CNA staff stated the resident did not need Geri Sleeves or that they were not sure the resident was supposed to wear them, while the DON stated the resident should have been wearing them as ordered because of purpura and very frail, thin skin. A nurse also stated the resident should be wearing Geri Sleeves if ordered and that removal should be documented.
Failure to Provide Supervision and Assistance With Eating
Penalty
Summary
The facility failed to provide necessary supervision and assistance with eating for one resident who had a history of aspiration pneumonia and dementia. The resident’s most recent MDS indicated cognitive intactness with a BIMS score of 13 out of 15 and showed the resident required supervision or touching assistance with eating. The care plan also identified the resident as supervised for eating and noted a nutritional risk related to swallowing disorder and aspiration risk, with instructions to provide encouragement, cueing, and assistance with feeding if needed. The resident’s CNA care card and active physician’s order did not indicate the need for supervision or assistance while eating, even though the care plan and nutritional assessments did. During multiple observations, the resident was seen eating meals alone in the room without staff within view, including breakfast and lunch meals. On one occasion, the resident was observed eating for several minutes without staff present, and a housekeeping manager later entered and began assisting only after the resident had already been eating alone. The resident stated staff had recently helped with every meal because of coughing and fear of choking, but that staff often left the tray and walked away. The resident also reported difficulty swallowing pills, shaking hands, weakness in the right arm, fatigue while eating, and trouble lifting drinks and finding the spoon on the tray. The resident’s son stated staff were supposed to sit with the resident because assistance and encouragement were needed, but instead trays were often removed with much of the meal uneaten. Nursing staff and the DON acknowledged that the care plan and CNA care card should match and that supervision meant the resident should always be within direct view of staff while eating.
Failure to Obtain Order for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to obtain a physician’s order for treatment before using zinc oxide cream on a newly developed stage 2 pressure ulcer on a resident’s right buttock. The resident was admitted with Parkinson’s disease and dementia, had severe cognitive impairment, was dependent on staff for all activities of daily living, and was identified as high risk for pressure ulcers. The resident’s record showed a new open area on the right inner buttock with measurements and stage 2 documentation, but the treatment and medication record sheets for August did not show any treatment for that wound. The facility’s records also showed that the resident previously had a left buttock zinc order that was discontinued after that area healed. When the right buttock wound was identified, staff documented the wound in progress notes and care plan entries, but the weekly skin checks recorded the skin as intact with no abnormalities. During interviews, nurses said they were applying zinc when changing the resident, but one nurse stated she did not obtain a new order when the wound opened. The wound nurse said she assessed the wound after being notified, but did not contact the provider for an order, stating that was the floor nurse’s responsibility. The DON stated that when a change in skin is noted, a nurse should notify the provider and obtain a physician’s order, but also said she did not think an order was needed because the resident’s wounds open frequently. The NP and MD both stated they expected to be notified of any new open skin area so they could enter an order for treatment, and both said they did not recall being contacted about the right buttock wound. The MD also stated that if zinc oxide is being used as the primary treatment for a pressure ulcer, an order is needed to track its use and the skin’s progress.
Missing Padded Side Rail for Resident with Fragile Skin
Penalty
Summary
The facility failed to maintain a safe environment for one resident by not keeping a padded right half side rail in place while the resident was in bed. The resident was admitted in August 2023 with diagnoses including dementia and malnutrition, and the most recent MDS dated 6/30/25 showed severe cognitive impairment with a BIMS score of 3 out of 15. Surveyors observed the resident in bed on 8/5/25 at 7:23 A.M. and 2:08 P.M., and again on 8/6/25 at 6:43 A.M., with the right side rail in place but without padding during each observation. The resident had a physician order, initiated 8/23/24, for a padded half side rail on the right side when in bed, and the care plan revised 1/21/25 noted that the resident pushes staff away during hands-on care but did not include the padded side rail. During interviews, a CNA stated the resident flails his/her arms in bed and requires the right side rail pad to protect the skin from injury, and said the pad had not been on when the shift started. A nurse stated the resident has fragile arm skin and that the pad should always be in place when the resident is in bed, but that CNAs sometimes forget to put it back on. Surveyor observation of the resident's arms showed bruises on the left arm and a bruise and scab on the right arm, which the CNA said were probably caused by the resident flailing his/her arms. The DON confirmed the right side rail pad should have been in place as ordered and stated the facility did not have a policy regarding padded side rails.
Inaccurate documentation of Geri Sleeve use
Penalty
Summary
The facility failed to ensure accurate medical record documentation for one resident when staff documented that the resident was wearing Geri Sleeves even though observations showed the sleeves were not being worn. Resident #14 was admitted in December 2023 with diagnoses including Alzheimer's disease and dementia, and the most recent MDS indicated a BIMS score of 3 out of 15, reflecting severe cognitive impairment. The MDS also indicated the resident was totally dependent on staff for all activities of daily living. During observations on 8/5/25, 8/6/25, and 8/7/25, Resident #14 was repeatedly seen sitting in a wheelchair in the dining room or being wheeled from the room, with forearms visible and no Geri Sleeves in place. The physician's order dated 2/27/25 directed staff to apply Geri Sleeves to both upper extremities every shift, with removal allowed for morning and evening care and toileting after meals. The resident's Kardex did not indicate Geri Sleeve use, and the pressure ulcer care plan included a handwritten intervention to apply Geri Sleeves every shift. The medical record did not show documentation of the resident removing the sleeves, yet the Treatment Record Sheet for 8/5/25, 8/6/25, and 8/7/25 was signed off as if the resident was wearing Geri Sleeves. CNA #2 stated the resident did not need Geri Sleeves anymore, CNA #1 said she did not put them on and did not know if the resident was supposed to wear them, and the DON and Nurse #1 stated that if the resident was not wearing them, staff should not document that he/she was.
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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 Wakefield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elmhurst Healthcare (the) | 1.4 mi | ★★★★★ | 0 | 0 |
| Melrose Healthcare | 1.5 mi | ★★★★★ | 0 | 0 |
| Regalcare At Wakefield | 1.7 mi | ★★★★★ | 13 | 0 |
| Life Care Center Of Stoneham | 2.1 mi | ★★★★★ | 15 | 0 |
| Bear Hill Healthcare And Rehabilitation Center | 2.2 mi | ★★★★★ | 7 | 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.