Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Greendale Forest Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with blood disorders had CBC blood draws documented as completed twice weekly in the MAR, despite lab reports showing only weekly draws. This occurred because two overlapping orders remained active in the MAR, and staff marked both as completed, leading to inaccurate medical records.
A resident at an LTC facility developed a severe pressure ulcer due to inadequate monitoring and delayed treatment. Despite being at risk for skin breakdown, the resident's skin assessments were not conducted weekly as required, leading to a significant delay in identifying and treating the wound. The wound worsened, resulting in hospitalization for infection and debridement.
The facility failed to conduct and document care plan meetings after quarterly and/or annual MDS assessments for six residents with cognitive impairments and other medical conditions. The Social Worker, responsible for scheduling these meetings, did not adhere to federal guidelines, and the Administrator was unaware of the oversight. This resulted in a deficiency in the care planning process.
A resident with COPD and CHF was not administered oxygen as prescribed, receiving two liters per minute instead of the ordered four liters. Observations and staff interviews revealed inconsistencies in monitoring and adjusting the oxygen concentrator, with staff inaccurately documenting the oxygen administration.
A resident was prescribed continuous oxygen at four liters per minute, but observations showed they were receiving only two liters. Despite this, the resident exhibited no respiratory distress. A nurse admitted to charting the incorrect oxygen level without verifying the concentrator setting. The DON confirmed no order existed to adjust the oxygen level, leading to inaccurate documentation on the MAR.
The facility failed to prevent urinary catheter bags from touching the floor for three residents, increasing the risk of infection. A resident with acute kidney failure and another with neurogenic bladder had catheter bags resting on the floor, despite care plans emphasizing closed drainage systems. A third resident with a suprapubic catheter also had a collection bag and tube touching the floor. Staff interviews confirmed the importance of keeping catheter bags off the floor to prevent contamination.
The facility failed to maintain a clean environment, with 20 out of 25 ceiling fans in resident halls observed to have a dark substance on their blades. The floor technician responsible for cleaning admitted the fans had not been cleaned for two weeks due to his absence, despite a weekly cleaning schedule. The DON and Administrator confirmed the housekeeping department's responsibility for this task.
The facility failed to post accurate RN staffing information for 16 days, as the Scheduler did not update the staffing sheets to reflect actual staff present. Despite RN coverage being confirmed through timecard punches, the posted information was incorrect due to the Scheduler's lack of awareness about updating requirements and completing sheets ahead of time.
A cognitively impaired resident sustained bruising and a nasal fracture of unknown source. Despite being entirely dependent on staff, the injury was not promptly reported to the physician or DON, leading to a delay in medical evaluation. The cause of the injury remains undetermined.
A resident with severely impaired cognition sustained an unexplained nasal fracture, but the facility failed to notify the physician immediately. The injury was first noticed by a nurse aide and reported to the night shift nurse, who did not consider it serious and left the notification to the day shift nurse. The physician was not informed until two days later, resulting in a delay in assessment and treatment.
A resident with severe cognitive impairment and total dependent care was found with swelling and bruising on her nose and under her eyes, later determined to be a nasal fracture. The injury was not immediately reported to facility management as required by policy, leading to a delay in addressing the injury and notifying the appropriate parties.
A cognitively impaired resident with multiple diagnoses sustained an injury of unknown source resulting in a nasal fracture. The facility failed to conduct neurological checks, obtain vital signs, or perform pain assessments. The injury was not documented or reported to the DON, physician, or responsible party in a timely manner.
Inaccurate MAR Documentation for Blood Draw Orders
Penalty
Summary
The facility failed to ensure the accuracy of the Medication Administration Record (MAR) for a resident with diagnoses including myelodysplastic syndromes, anemia, and diabetes. The MAR showed that a scheduled CBC blood draw was documented as completed twice a week, on both Wednesdays and Thursdays, instead of the ordered frequency of once a week. The laboratory reports, however, confirmed that the blood draws were only performed once weekly. This discrepancy was due to the presence of two active orders in the MAR—one for Thursdays and another for Wednesdays—without discontinuing the earlier order when the new one was entered. Staff interviews revealed that nurses and medication aides marked the MAR as completed based on the assumption that the task was done, with one aide admitting to marking the MAR in error. The phlebotomist clarified that the blood draws were changed from Thursdays to Wednesdays in March, but the MAR was not updated accordingly. The DON acknowledged that the previous order should have been discontinued when the new order was implemented, and the administrator confirmed that tasks should only be marked as completed when actually performed.
Failure to Monitor and Treat Pressure Ulcer Timely
Penalty
Summary
The facility failed to implement effective systems for identifying and managing skin breakdown, leading to a significant delay in treatment for a resident. Upon re-admission, the resident's skin was intact, but by early January, excoriation was noted on the buttocks. However, there were no further documented assessments until mid-January, when a pressure wound was identified. This lack of timely documentation and assessment contributed to the deterioration of the wound, which eventually required hospitalization for an infection. The resident, who was at risk for skin breakdown due to conditions such as coronary artery disease and renal insufficiency, was not consistently monitored as per the care plan. The care plan required weekly skin assessments and notification of any changes, but these were not documented consistently. The resident's medical records showed a gap in skin assessments from mid-December to mid-January, during which time the pressure wound developed and worsened. Interviews with staff revealed a lack of clarity and consistency in conducting and documenting skin assessments. The Treatment Nurse was only informed of the wound's severity in mid-January, and despite starting treatment, the wound continued to deteriorate. The facility's failure to adhere to its own protocols for skin assessments and timely intervention contributed to the resident's condition worsening, ultimately leading to hospitalization.
Failure to Conduct and Document Care Plan Meetings
Penalty
Summary
The facility failed to conduct and document care plan meetings after the completion of quarterly and/or annual Minimum Data Set (MDS) assessments for six residents. These residents included individuals with varying degrees of cognitive impairment and other medical conditions such as diabetes mellitus, hypertension, heart disease, congestive heart failure, dementia, and chronic kidney disease. The care plan meetings, which are essential for updating and reviewing the care needs of residents, were not held as required by federal guidelines. Interviews with the facility's Social Worker and MDS Coordinator revealed that the Social Worker was responsible for scheduling these meetings using the MDS assessment schedule provided by the MDS Coordinator. However, the Social Worker was unable to provide reasons for the failure to conduct these meetings, despite acknowledging the need for them. In some cases, attempts to contact resident representatives were unsuccessful, but this did not prevent the facility staff from holding the meetings. The Social Worker admitted to not documenting a care plan meeting for one resident and was unsure why others were not scheduled. The facility Administrator confirmed that the Social Worker was tasked with scheduling the care plan meetings and was unaware that the meetings had not been conducted as required. The Administrator emphasized that care plan meetings should be scheduled according to federal timeframes, but this was not adhered to, resulting in a deficiency in the facility's care planning process.
Failure to Administer Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to administer supplemental oxygen as prescribed by the physician for a resident with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). The physician's order required continuous oxygen at four liters per minute via nasal cannula. However, observations on two separate occasions revealed the resident receiving only two liters per minute, despite the absence of respiratory distress. The resident's care plan and medication administration record (MAR) indicated the need for four liters per minute, yet the actual administration did not align with these directives. Interviews with nursing staff revealed inconsistencies in monitoring and adjusting the oxygen concentrator. Nurse #2, who worked the night shift, acknowledged that the resident was known to adjust the oxygen concentrator and admitted to not recalling the specific time the concentrator was checked. Nurse #3, from the day shift, admitted to charting the resident on four liters of oxygen without verifying the concentrator's setting. The Director of Nursing confirmed there was no order to titrate the oxygen to two liters per minute, and the staff had been inaccurately documenting the oxygen administration in the MAR.
Inaccurate Documentation of Oxygen Therapy
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident receiving oxygen therapy. Physician orders dated March 20, 2025, specified that the resident should receive continuous oxygen at four liters per minute via nasal cannula every shift due to respiratory disease. However, observations on March 25 and March 26, 2025, revealed that the resident was receiving only two liters per minute, contrary to the physician's orders. Despite this discrepancy, the resident showed no signs of respiratory distress during these observations. Nurse #3, who worked the 7:00 am to 3:00 pm shift, admitted to charting that the resident was receiving four liters of oxygen without verifying the actual setting on the oxygen concentrator. The Director of Nursing, upon reviewing the resident's electronic medical record, confirmed that there was no order to adjust the oxygen to two liters per minute, and the nursing staff had been inaccurately documenting the oxygen administration on the Medication Administration Record (MAR). This failure to verify and accurately document the resident's oxygen therapy led to the deficiency.
Failure to Prevent Catheter Bags from Touching the Floor
Penalty
Summary
The facility failed to prevent urinary catheter bags from touching the floor, which is a critical measure to reduce the risk of infection. This deficiency was observed in three residents who had urinary catheters. Resident #8, who was admitted with acute kidney failure and urinary retention, was found with his catheter drainage bag resting on the floor multiple times. Despite being dependent on staff for all activities of daily living and having a care plan that included maintaining a closed drainage system, the care plan did not specify keeping the catheter bag off the floor. Staff interviews confirmed that the catheter bag should not touch the floor to prevent contamination. Resident #14, diagnosed with neurogenic bladder and moderately cognitively impaired, also had a urinary catheter bag that was observed lying on the floor. The care plan for Resident #14 included maintaining a closed drainage system but did not address keeping the bag off the floor. During a hospital stay, Resident #14 was treated for a urinary tract infection, highlighting the importance of proper catheter care. Staff acknowledged the issue and attempted to rectify the situation by adjusting the bed height and repositioning the bag. Resident #5, who had a suprapubic catheter due to urine retention, was similarly affected. Observations revealed that the urinary collection bag and the tube used to empty it were touching the floor. The care plan for Resident #5 included maintaining a closed drainage system but lacked specific instructions to keep the bag off the floor. The Director of Nursing confirmed that the urinary collection bags and tubes should not be in contact with the floor to prevent contamination.
Failure to Maintain Clean Ceiling Fans in Resident Halls
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by the presence of a dark grey/black colored substance on the blades of ceiling fans in 8 out of 8 resident halls. Observations conducted on various halls revealed that 20 out of 25 ceiling fans had this substance on all five blades. Interviews with housekeeping staff, the housekeeping manager, and the floor technician confirmed that the ceiling fans were supposed to be cleaned weekly. However, the floor technician, who was responsible for this task, admitted that the fans had not been cleaned for two weeks due to his absence. The Director of Nursing and the Administrator both stated that the housekeeping department was responsible for cleaning the ceiling fans according to a weekly schedule. Despite this expectation, the observations and staff interviews indicated a lapse in the cleaning schedule, leading to the accumulation of the dark substance on the ceiling fans. This deficiency highlights a failure in maintaining the facility's cleanliness standards, as required to ensure a safe and comfortable environment for residents.
Inaccurate RN Staffing Information Posted
Penalty
Summary
The facility failed to post accurate Registered Nurse (RN) staffing information for 16 out of 114 days reviewed. The daily posted nurse staffing sheets from December 2024 to March 2025 showed that there were no RNs documented as working for all three shifts on specific days across these months. However, a review of employee timecard punches confirmed that there had been RN coverage in the building on those days, indicating that the posted staffing information was incorrect. The Scheduler, responsible for staff posting, stated she was unaware of the requirement to adjust the posted staffing information to reflect the actual staff present. She completed the staffing sheets ahead of time based on the staff work schedule and did not update them to accurately reflect the actual staffing when she was off on weekends or vacation. The Administrator acknowledged awareness of the requirement to adjust the posted staffing but was unaware that this was not being done, and the Scheduler did not know the posted staffing should be updated with the actual staff on each shift.
Failure to Protect Resident from Injury of Unknown Source
Penalty
Summary
The facility failed to protect a cognitively impaired resident from an injury of unknown source, resulting in bruising under the eyes and a fracture of the nasal bridge. The resident, who had severe cognitive impairment, quadriplegia, and dementia, was entirely dependent on staff for activities of daily living. On the night of the incident, a nurse aide noticed swelling and bruising on the resident's nose and under her eyes. Despite the resident's inability to verbalize the cause of her injury, the nurse on duty administered Tylenol and applied an ice pack but did not report the injury to the physician or the Director of Nursing (DON) until the following day. An x-ray later revealed a minimally displaced fracture of the nasal bridge. The investigation revealed that the resident had no history of falls and was on anticoagulant medication, which could cause bruising. Staff interviews indicated that the resident had been resistive to care at times but had not been observed falling or having any accidents that could explain the injury. The resident's roommate, who was alert and oriented, also did not witness any mistreatment or incidents that could have caused the injury. The nurse on duty during the night of the incident did not receive any report of an injury from the day shift nurse and decided to leave the matter for the morning nurse to address. The Director of Nursing and the Administrator were not made aware of the injury until two days later. The physician was notified and ordered an x-ray, which confirmed the nasal fracture. Despite a thorough investigation, including interviews with staff and the resident's roommate, the cause of the injury remained undetermined. The facility's failure to promptly report and investigate the injury of unknown source led to a delay in appropriate medical evaluation and intervention for the resident.
Failure to Notify Physician of Resident's Injury
Penalty
Summary
The facility failed to notify the physician of a resident's change in condition when an injury of unknown source was identified. The resident, who had severely impaired cognition, was observed with unexplained bruising and swelling under the eye, and x-rays later confirmed a fracture of the nasal bridge. The injury was first noticed by a nurse aide, who reported it to the assigned nurse. However, the nurse did not notify the physician, believing the injury was not serious and deciding to leave the notification to the day shift nurse. This resulted in a delay in the physician being informed and the injury being properly assessed and treated. The resident's progress notes from the time of the injury did not show any evidence that the physician was notified. Interviews with the nursing staff revealed that the night shift nurse observed the bruising and swelling but did not consider it necessary to notify the physician immediately. The day shift nurse also failed to notify the physician, assuming the Director of Nursing (DON) would handle it. The DON was not made aware of the injury until two days later, at which point the physician was finally notified, and an x-ray was ordered, revealing the nasal fracture. The physician confirmed that he was not informed of the injury until two days after it occurred and stated that he should have been notified sooner. The facility's administrator acknowledged that the night shift nurse should have reported the injury immediately to both the DON and the physician. The delay in notification and assessment of the injury was a clear deviation from the facility's protocol for handling injuries of unknown source, which requires immediate reporting to the DON and the physician for further orders and treatment decisions.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to implement their policy for injuries of unknown source, which required staff to immediately report the injury to facility management. A staff member did not report unexplained bruising under the eyes and over the nose of a resident to facility management as soon as the injury was observed. The resident, who had severe cognitive impairment and required total dependent care, was found with swelling and bruising on her nose and under her eyes, which was later determined to be a minimally displaced fracture of the nasal bridge. On the night of the incident, a nurse aide reported the swelling to a nurse, who instructed the aide to apply an ice pack and administered Tylenol. The nurse did not notify the Administrator or the Director of Nursing (DON) immediately, as required by the facility's policy. The nurse believed the injury was minor and decided to let the day shift nurse notify the doctor. The next day, another nurse observed the bruising and swelling but did not immediately notify the DON, delaying the reporting of the injury. The DON was not made aware of the injury until two days later, at which point an investigation was initiated, and an x-ray confirmed the nasal fracture. The failure to follow the facility's protocol for reporting injuries of unknown source led to a delay in addressing the resident's injury and notifying the appropriate parties. Staff interviews revealed that the nurses involved did not follow the established procedures for reporting and documenting the injury, contributing to the deficiency.
Failure to Monitor and Report Injury of Unknown Source
Penalty
Summary
The facility failed to monitor a resident following the identification of an injury of unknown source that resulted in bruising and a fracture of the nasal bridge. Neurological checks were not conducted following the unwitnessed head injury, vital signs were not obtained, and pain assessments were not conducted. This occurred for a cognitively impaired resident who was admitted with diagnoses including cerebral vascular accident (CVA), quadriplegia, and dementia. The resident required total dependent care by staff for activities of daily living (ADLs) and had no history of falls or rejection of care. On the night of the incident, a nurse aide reported swelling on the bridge of the resident's nose to the nurse, who instructed the aide to apply an ice pack and administered Tylenol. However, there was no documentation of the injury, neurological checks, vital signs, or pain assessments in the resident's progress notes. The nurse did not notify the Director of Nursing (DON), the physician, or the resident's responsible party about the injury. The following day, another nurse observed the bruising and swelling but did not complete an incident report or notify the DON immediately. The Director of Nursing was not made aware of the injury until two days later, at which point an investigation was initiated, and the responsible party and physician were notified. An x-ray revealed a minimally displaced fracture of the nasal bridge. The facility's failure to follow protocol for monitoring and reporting the injury of unknown source, including conducting neurological checks and obtaining vital signs, led to the deficiency. Staff interviews revealed a lack of immediate action and proper documentation following the identification of the injury.
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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 Snow Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth-farmville | 10.5 mi | ★★★★★ | 5 | 0 |
| Nc State Veterans Home-kinston | 10.6 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Kinston | 11.3 mi | ★★★★★ | 8 | 0 |
| Harmony Hall Nursing And Rehabilitation Center | 12.1 mi | ★★★★★ | 6 | 0 |
| Ayden Court Nursing And Rehabilitation Center | 12.8 mi | ★★★★★ | 6 | 1 |
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