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 Greenhaven Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe dementia and a high wandering risk exited through an employee door after a dietary aide mistook him for a visitor and did not stop him from following outside. Staff later found him missing, and law enforcement located him about 1 mile away lying in a busy roadway, cold and wet, with serious injuries including acute subdural hematomas and facial fractures.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
A resident with severe cognitive impairment and a history of stroke received aspirin every other day without a specified dosage in the medication order. Nursing staff administered 81 mg based on assumption, and the DON confirmed the order lacked required clarification. The deficiency was identified during a surveyor review.
Three residents were not offered the pneumococcal 20-valent conjugate vaccine (PCV20) as recommended by CDC/ACIP guidelines. Facility records showed that these residents had either declined older pneumococcal vaccines or had no documentation of being offered PCV20, and the facility's immunization policy did not include PCV20. The DON/Infection Preventionist was unaware of the requirement to offer PCV20, resulting in the deficiency.
Over a four-month period, the facility did not act upon or resolve grievances raised by the Resident Council, including concerns about cleanliness, call bell response times, missing items, and staff conduct. Grievances were not documented, investigated, or followed up on as required, and residents were not informed of any actions taken, as confirmed by staff and resident interviews.
A resident with severe cognitive impairment and a history of intracerebral hemorrhage was admitted and had a baseline care plan completed, but the facility did not provide a copy of this care plan to the responsible party as required. Staff and leadership interviews confirmed the expectation to deliver the care plan within 48 hours, but there was no documentation or confirmation that this occurred.
A resident with severe cognitive impairment and a history of stroke received aspirin every other day without a specified dosage in the physician's order. Despite repeated consultant pharmacist recommendations to clarify the dosage, the facility did not address the issue, and nursing staff administered 81 mg aspirin based on assumption rather than a documented order. The DON was unaware of the unresolved recommendations until notified by surveyors.
A resident was not protected from the wrongful use of their belongings or money, as required. The facility failed to ensure proper safeguarding, resulting in unauthorized use.
A resident with a history of cardiac arrhythmia, dementia, and hypertension, who had documented bilateral cataracts and blurred vision, was not accurately coded for visual impairment on MDS assessments. Despite medical records and resident reports indicating vision problems, staff responsible for completing the MDS were unaware of the ophthalmology findings and coded the resident as having adequate vision, omitting necessary care plan interventions.
A resident who was non-ambulatory and dependent on staff for personal hygiene had overgrown, thick, and yellow toenails. Despite being unable to have her toenails trimmed by nursing staff and expressing a desire for podiatry care, no podiatry consult was arranged or documented. Communication lapses between a nursing assistant and nurse, as well as a missed opportunity to refer the resident to the podiatrist after she declined nail care, led to the deficiency.
A resident with severe cognitive impairment was sexually abused by his roommate, who was also cognitively impaired. Staff discovered the incident during rounds, finding one resident fondling the other's genitals while the latter was asleep and unable to defend himself. There was no prior history of sexually inappropriate behavior by the perpetrator, and both residents had significant dementia. The incident was directly observed and confirmed by staff, and the affected resident's family confirmed his inability to protect himself.
A nursing assistant observed a resident sexually assaulting another cognitively impaired resident and, instead of remaining in the room to protect the victim as required by facility policy, left to seek help from another staff member. The staff member was aware of the policy to stay with the resident and use available means to call for assistance but chose to leave the room, resulting in a failure to ensure immediate resident safety during the incident.
The facility failed to allow residents assessed as safe smokers to smoke independently at any time of their choice, enforcing a strict smoking schedule instead. This deficiency affected multiple residents who expressed dissatisfaction with the restricted smoking times, despite being assessed as safe smokers.
The facility failed to update care plans for four residents to reflect their current Smoking Evaluations and Advance Directives. Three residents had their Smoking Evaluations updated to show they could smoke independently, but their care plans still required supervision. Another resident's care plan was not updated to reflect a change to Do Not Resuscitate (DNR) status.
The facility's QAA Committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in Grievances, Care Plan timing/revision, and Medication Storage. The facility did not investigate and resolve grievances for five residents, failed to update care plans for four residents, and improperly managed medication storage, including the removal of expired medications and proper labeling of inhalers and multidose vials.
The facility failed to monitor antibiotic usage for six months, from August 2023 to January 2024, as required by its Antibiotic Stewardship policy. The ADON could not locate the necessary information, and the previous ADON responsible for the program left in December 2023. The DON confirmed that the monitoring was not conducted as expected.
The facility failed to document COVID-19 vaccine education for five residents and did not offer the vaccine to three of these residents. Interviews revealed that consents and educational materials were missing from the records, indicating a lapse in documentation and infection control procedures.
A facility failed to apply a prescribed splint for a resident with a left-hand contracture. Despite physician orders and occupational therapy recommendations, the splint was not consistently applied, and staff were unaware of the resident's need for the splint. Observations confirmed the splint was not in place, and staff interviews revealed a lack of knowledge about the splint's application and location.
The facility failed to remove expired medications and supply kits from the medication storage room. Observations revealed expired multi-dose vials of Influenza Vaccine and Levemir insulin, as well as expired Secondary Administration Sets, Dressing Change Tray, Foley Catheter Insertion Tray, and Pivodon-Iodine Swab sticks. Staff interviews indicated that nurses were responsible for discarding expired items, but this was not consistently done.
The facility failed to administer influenza and pneumonia vaccines to two residents who had signed consent forms. Both the Infection Preventionist and the DON were unaware of why the vaccines were not given, despite the consents being in place.
Unsupervised Exit by Cognitively Impaired Resident
Penalty
Summary
The facility failed to supervise a severely cognitively impaired resident who was at risk for wandering and unsupervised exits. The resident had a history of severe chronic dementia/Alzheimer’s disease, was ambulatory, and had a wandering risk score of 13. He was admitted for respite care with a wanderguard bracelet on his left ankle, and his care plan identified wandering and unsupervised exits as concerns. The employee exit door he used to leave the building did not have a transmitter sensor, and the magnetic lock was released when a dietary aide entered a code on the keypad. On the evening of the incident, the resident was seen wandering in the halls and asking staff where the door was to get out. A dietary aide encountered him near the employee exit, believed he was a visitor because he was wearing street clothes, a hat, and walking unassisted, and directed him toward the front entrance. The dietary aide then exited through the employee door, entered the code to unlock it, and left the building without realizing the resident had followed him outside. The aide later saw the resident walking outside toward the front of the building but did not intervene. Staff did not immediately locate the resident after he was missing. Searches were initiated after medication staff could not find him in his room, and the resident was eventually found by law enforcement approximately 1 mile from the facility lying in the road near a busy five-lane intersection with interstate ramps. He was cold, wet, and shaking, and a bystander was trying to help him out of the street. He was returned to the facility and later taken to the hospital, where he was diagnosed with acute subdural hematomas, a midline shift, and facial fractures including maxillary sinus, orbit, and zygomatic arch fractures. The trauma physician stated the injuries were life threatening and consistent with a fall, and that the subdural hematomas were new injuries occurring within the prior 12 hours.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Clarify Aspirin Dosage in Medication Order
Penalty
Summary
The facility failed to ensure that medication orders for a resident met professional standards of quality, specifically by not clarifying the dosage of aspirin to be administered. A resident with a history of dementia, cerebral stroke syndrome, and cerebrovascular disease was admitted with an order for aspirin to be given every other day, but the dosage was not specified in the Medication Administration Record (MAR) from January to July 2025. Despite this omission, nursing staff administered 81 mg of aspirin every other day from the facility's over-the-counter stock, based on the nurse's assumption and belief in a standing order, which was not present in the resident's physician orders. Interviews revealed that the nurse responsible for administering the medication was unaware of the missing dosage in the original order and relied on her understanding of typical practice for residents with a history of stroke. The Director of Nursing confirmed that there were two available dosages of aspirin in stock (81 mg and 325 mg) and acknowledged that the order should have been clarified to specify the correct strength. The issue was only identified after surveyor intervention, and the resident's physician was not available for interview during the survey.
Failure to Offer Pneumococcal 20-Valent Conjugate Vaccine to Eligible Residents
Penalty
Summary
The facility failed to offer the pneumococcal 20-valent conjugate vaccine (PCV20) to three out of five residents reviewed for pneumococcal immunizations. According to the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP), adults aged 65 years or older, and those aged 19-64 with certain underlying medical conditions, should be routinely offered PCV20 or PCV15 if they have not previously received a pneumococcal conjugate vaccine or if their vaccination history is unknown. Record reviews showed that residents had either declined older pneumococcal vaccines (PCV13 or PPSV23) or there was no documentation of being offered PCV20, and there was no evidence that PCV20 was offered or administered since the last recertification or prior to admission. The facility's immunization policy, last reviewed in March 2024, only referenced offering PCV13 or PPSV23, not PCV20. Documentation for the affected residents did not indicate that PCV20 was offered or declined, and there was no record of prior receipt of PCV20. During an interview, the DON/Infection Preventionist stated she was unaware of the need to offer PCV20 and confirmed that the facility had only been offering PCV13 and PPSV23 to residents.
Failure to Address and Communicate Resident Council Grievances
Penalty
Summary
The facility failed to act upon and resolve grievances reported by the Resident Council over a four-month period, as evidenced by record review, staff, and resident interviews. Resident Council minutes from March through June documented multiple grievances, including issues with cleanliness, call bell response times, missing personal items, staff attitudes, and inadequate assistance during certain shifts. Despite these concerns being voiced during meetings, there was no evidence that the grievances were recorded on the Facility Concern/Grievance Form, investigated, or resolved as required by the facility's grievance policy. Additionally, there was no documentation of follow-up or communication to the Resident Council regarding the status or resolution of their concerns. Interviews with the Activities Director and Administrator confirmed that while Resident Council minutes were provided to the Administrator, neither party completed grievance forms for council concerns nor documented actions taken to address them. The Activities Director was unaware of the requirement to follow up with the Resident Council, and the Administrator acknowledged that actions to address grievances were not documented or communicated. Residents reported that their repeated grievances were not addressed or followed up on, indicating a systemic failure to manage and resolve Resident Council concerns in accordance with facility policy.
Failure to Provide Baseline Care Plan to Responsible Party
Penalty
Summary
The facility failed to provide a copy of the baseline care plan to the responsible party for one resident who was admitted and later readmitted with a diagnosis that included non-traumatic intracerebral hemorrhage and was noted to be severely cognitively impaired. Documentation showed that a baseline care plan was completed by a unit manager within the required timeframe, but there was no evidence in the medical record that a copy of this care plan was given to the resident or the responsible party, despite the resident having a family member listed as the responsible party. Multiple attempts to interview the responsible party were unsuccessful, and staff interviews revealed that the admitting nurse did not complete or provide a summary of the baseline care plan. Further interviews with facility leadership, including another unit manager and the DON, confirmed that the expectation was for the baseline care plan to be developed and provided to the resident or responsible party within 48 hours of admission. However, the DON could not confirm that the summary was ever provided in this case. The administrator also stated that it was expected for the resident and/or responsible party to receive a written summary of the baseline care plan within 48 hours, but this did not occur for the resident in question.
Failure to Address Pharmacist's Recommendation for Aspirin Dosage Clarification
Penalty
Summary
The facility failed to address discrepancies identified by the consultant pharmacist regarding a resident's aspirin order. The resident, who had diagnoses including dementia, cerebral stroke syndrome, and cerebrovascular disease, was admitted with severe cognitive impairment and a history of stroke. The resident's Medication Administration Records over several months included an order for aspirin every other day, but the strength of the medication was not specified. The consultant pharmacist noted the missing dosage in multiple monthly reviews, but there was no documentation that the facility addressed or clarified the recommendation. Interviews revealed that a nurse administered 81 mg aspirin every other day from the facility's stock, believing it was the correct order, despite the absence of a specific physician's order for aspirin. The DON, who had recently assumed her role, discovered that several pharmacy recommendations, including the missing dosage clarification, had not been completed by previous nursing leadership. The DON was unaware of the missing dosage until it was brought to her attention by surveyors.
Failure to Protect Resident's Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or inappropriate use. Specific details about the actions or inactions that led to this event are not provided in the report excerpt. No additional information about the resident's medical history or condition at the time of the deficiency is included.
Failure to Accurately Code MDS Assessment for Visual Impairment
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of vision for a resident with a history of cardiac arrhythmia, dementia, and essential hypertension. The resident's electronic medical record included an ophthalmology consultation that documented bilateral cataracts and blurred vision, with cataract surgeries scheduled but delayed due to a hospital stay. Despite this, both the Significant Change in Status and the most recent MDS assessments completed by two different MDS nurses indicated the resident had adequate vision and corrective lenses, with no mention of visual impairment or cataracts in the care plan. Interviews with the resident confirmed ongoing difficulty with vision, and staff interviews revealed that the MDS nurses were unaware of the ophthalmology findings at the time of assessment. Both nurses acknowledged that the resident should have been coded for visual impairment based on the available medical information. The administrator also confirmed that the MDS assessments should have accurately reflected the resident's medical condition.
Failure to Arrange Podiatry Care for Dependent Resident
Penalty
Summary
A resident with a history of cellulitis of the left lower limb, chronic kidney disease, and congestive heart failure was admitted to the facility and was dependent on staff for personal hygiene, including nail care. The resident was non-ambulatory and cognitively intact. During a quarterly assessment, it was noted that the resident's great toenails were long, thick, and yellow, extending beyond the end of the toes. The resident reported that nursing staff had not offered a podiatry consult and expressed a desire for a podiatry visit from the facility's onsite provider. There was no documentation in the medical record indicating that the resident had been seen by podiatry. A nursing assistant observed the resident's toenails to be overgrown and reported feeling unable to trim them, stating she notified a nurse of the need for a podiatry consult. However, the nurse was unaware of this report and had not initiated a consult. The DON stated that toenail care was to be provided by nursing staff, and if unsuccessful, a podiatry consult should be offered. The DON confirmed that although an attempt to trim the resident's toenails was made in May, which the resident declined, a podiatry consult was not offered at that time as required.
Failure to Protect Resident from Sexual Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment was not protected from sexual abuse by another resident. The incident involved two male residents, both diagnosed with dementia and significant cognitive deficits. One resident, who was dependent for most activities of daily living and unable to protect himself, was found in his bed with his brief open while his roommate was observed by staff to be fondling his genitals. The cognitively impaired resident was asleep and unable to respond or defend himself during the incident. Staff interviews and written statements confirmed that the inappropriate contact was directly observed by a nurse aide and a medication aide, who intervened to stop the behavior. Prior to this event, there was no documented history or care plan indication that the resident who initiated the contact had exhibited sexually inappropriate behaviors. Both residents had been roommates for approximately two weeks, and staff had not reported any prior concerns regarding inappropriate touching or aggression between them. The incident was discovered during routine rounds, and staff responded by separating the residents and assessing for injuries, of which none were found. The resident who was abused was severely cognitively impaired, unable to recall the incident, and had a history of behavioral disturbances but no recent behaviors. The other resident also had significant cognitive and intellectual deficits and was not aware of his actions. The family of the abused resident expressed that he would have been unable to defend himself and would have been upset by such an incident. The facility's failure to anticipate or prevent this event, despite both residents' vulnerabilities, resulted in a violation of the requirement to protect residents from all forms of abuse, including sexual abuse.
Failure to Follow Abuse Policy During Resident-to-Resident Sexual Assault
Penalty
Summary
The facility failed to follow its abuse prevention policy when a nursing assistant (NA) observed a resident-to-resident sexual assault and left the room to seek assistance, rather than remaining with the resident to ensure their immediate safety. The incident involved two residents who were roommates, both of whom had significant cognitive impairments. During routine rounds, the NA discovered one resident touching the genitals of the other, who appeared to be sleeping and had removed his own undergarment. The NA attempted to verbally redirect the resident but was unsuccessful, prompting her to leave the room to find help from another staff member. Upon returning to the room with a medication aide (MA), the staff intervened and separated the residents. The MA then called a nurse for further assistance. Interviews with staff confirmed that the NA was aware of the facility's policy, which required staff to remain with the resident and ensure their safety during incidents of abuse, using available means such as the call light, calling out for help, or using a phone. Despite this training, the NA chose to leave the room, believing it would be faster to get help in person rather than using the call light. The facility's abuse policy, last revised in 2017, specifically states that all necessary steps must be taken to prevent further acts of abuse and that staff are to be trained and retrained regularly on these procedures. Multiple staff interviews, including those with supervisory and administrative personnel, confirmed that the NA's actions were inconsistent with facility policy and expectations. The incident directly affected one of the two residents reviewed for abuse and was substantiated through record review and staff interviews.
Facility Restricts Smoking Times for Safe Smokers
Penalty
Summary
The facility failed to allow residents assessed to be safe smokers the ability to smoke independently at any time of their choice. This deficiency was identified through observations, resident and staff interviews, and record reviews. The facility's Smoking Policy, revised on 10/15/22, stated that residents identified as safe smokers could smoke unsupervised at any time. However, the facility enforced a strict smoking schedule, limiting smoking times to 11:00 AM, 2:00 PM, and 5:00 PM, even for residents assessed as safe smokers. Resident #47, with intact cognition and a history of diabetes and stroke, was assessed as a safe smoker on 3/2/24. Despite this assessment, the resident reported being restricted to the designated smoking times. Similarly, Resident #8, with intact cognition and a history of diabetes and cerebrovascular disease, was also assessed as a safe smoker but was limited to the same smoking schedule. Resident #69, with moderately impaired cognition and a history of non-traumatic spinal cord dysfunction, expressed dissatisfaction with the restricted smoking times despite being assessed as a safe smoker. Interviews with the Activities Director and the Interim Administrator confirmed that the supervised smoking schedule applied to all smokers, regardless of their assessment status. The Interim Administrator acknowledged that the issue needed to be addressed, indicating that the supervised smoking schedule was already in place when he assumed his role in mid-January. This practice of restricting smoking times for safe smokers was contrary to the facility's policy and the residents' rights to self-determination and choice.
Failure to Update Care Plans for Smoking Evaluations and Advance Directives
Penalty
Summary
The facility failed to review and revise the care plans for four residents as required. Resident #47, #8, and #69 had their Smoking Evaluations updated to reflect that they were safe, independent smokers, but their care plans were not revised accordingly. Resident #47's care plan still indicated the need for supervision while smoking, despite the evaluation showing they could smoke independently. Similarly, Resident #8's care plan continued to list them as an unsafe smoker requiring supervision, and Resident #69's care plan did not reflect their ability to smoke independently as per the latest evaluation. Interviews with the Director of Nursing and the MDS nurse confirmed that the care plans were not updated to match the Smoking Evaluations, and the MDS nurse acknowledged the need to modify the care plans to reflect the current evaluations accurately. Additionally, Resident #46's care plan was not updated to reflect a change in their Advance Directive. The resident had a physician's order to change their code status to Do Not Resuscitate (DNR) on 1/4/24, and a signed DNR form was present in the paper chart. However, the care plan revised on 1/25/24 still indicated a full code status. The MDS nurse confirmed that she missed updating the care plan to reflect the new DNR order. The facility's Administrator also acknowledged that the care plan should have been updated to reflect the correct code status. These deficiencies indicate a failure in the facility's process for ensuring that care plans are reviewed and revised in a timely manner to reflect significant changes in residents' evaluations and medical directives. The discrepancies between the Smoking Evaluations and the care plans, as well as the failure to update the code status in the care plan, were confirmed through staff interviews and record reviews.
Repeated Deficiencies in Grievances, Care Plan Timing/Revision, and Medication Storage
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions following recertification and complaint surveys. This resulted in repeated deficiencies in the areas of Grievances, Care Plan timing/revision, and Medication Storage. Specifically, the facility did not investigate and resolve grievances for five residents, failed to review and revise care plans for four residents, and did not properly manage medication storage, including the removal of expired medications and proper labeling of inhalers and multidose vials. These issues were identified during surveys conducted on 4/12/21, 1/13/23, and 3/14/24, indicating a pattern of the facility's inability to sustain an effective QAA program. For Grievances, the facility failed to investigate and resolve grievances for five residents and did not maintain evidence demonstrating the results of the grievances. In the area of Care Plan timing/revision, the facility did not update care plans to reflect changes in residents' conditions, such as smoking evaluations and advance directives. Regarding Medication Storage, the facility did not remove expired medications, label inhalers and multidose vials correctly, or store medications as per pharmacy instructions. These repeated deficiencies highlight the facility's ongoing challenges in maintaining compliance with regulatory standards.
Failure to Monitor Antibiotic Usage
Penalty
Summary
The facility failed to monitor antibiotic usage for six out of thirteen months reviewed, specifically from August 2023 to January 2024. The facility's policy on Antibiotic Stewardship, revised in March 2024, mandates the monitoring of antibiotic use as part of its infection prevention control program. During an interview, the Assistant Director of Nursing (ADON) was unable to locate antibiotic stewardship information for the specified months. The Regional Nurse Consultant indicated that the previous ADON, who was responsible for the antibiotic stewardship, left in December 2023, and attempts to contact her were unsuccessful. The Director of Nursing (DON) stated that the expectation was to monitor antibiotics and infections from the first day of antibiotic use, ensuring necessity, tracking, and trending infections, and reviewing specifics monthly. However, this monitoring was not conducted for the months in question.
Deficiency in COVID-19 Vaccine Documentation and Offering
Penalty
Summary
The facility failed to document the education regarding the benefits and potential side effects of the COVID-19 immunization for five residents and did not offer the COVID-19 vaccine to three of these residents. Specifically, the medical records for Residents #46, #14, #26, #33, and #54 lacked documentation of education about the COVID-19 vaccine. Additionally, Residents #26, #33, and #54 were not offered the vaccine, and their vaccination status was not recorded in their medical records. These deficiencies were identified through record reviews and staff interviews, revealing gaps in the facility's infection control practices. Interviews with the Infection Preventionist and the Director of Nursing (DON) highlighted the facility's inability to locate consents and educational documentation regarding the COVID-19 vaccine. The Infection Preventionist, who had been employed for 1.5 weeks, indicated that some consents were in the computer while others were on paper, but none could be found. The DON confirmed that the vaccine process was initiated upon admission, but the consents and educational materials were missing from the records, indicating a lapse in the facility's documentation and infection control procedures.
Failure to Apply Prescribed Splint for Resident with Contracture
Penalty
Summary
The facility failed to apply a prescribed splint for a resident with a left-hand contracture. Resident #33, who was admitted with diagnoses including hypertension, diabetes, cerebral vascular accident, and left-hand contracture/hemiparesis, was documented to require a left-hand splint as part of their care plan. Despite physician orders and occupational therapy recommendations, the splint was not consistently applied, and staff were unaware of the resident's need for the splint. Observations over several days confirmed that the splint was not in place, and staff interviews revealed a lack of knowledge about the splint's application and location. The occupational therapy discharge summary indicated that the resident tolerated the splint for up to four hours daily, and the physician order specified daily application of the splint. However, multiple observations showed the resident without the splint, and staff interviews confirmed that the splint was not being applied as required. The Director of Nursing and various nurse aides and nurses were unaware of the splint order, and the splint could not be located in the resident's room. The Medication Administration Records (MAR) for February and March 2024 documented the application of the splint, but physical checks during the survey period showed the splint was not in place. The Director of Nursing acknowledged the discrepancy and stated that the splint order would be placed on hold until the resident could be re-evaluated and staff trained on the application process. The lack of proper documentation and staff awareness led to the failure in providing the necessary care for the resident's contracture management.
Expired Medications and Supplies Found in Storage Room
Penalty
Summary
The facility failed to remove expired medications and supply kits from the medication storage room. During an observation of the medication storage room, it was found that there were two opened and undated multi-dose vials of Influenza Vaccine, one multi-dose vial of Influenza Vaccine opened on 11/8/23, and one expired multidose vial of Levemir insulin. Additionally, inside the cabinets, there were 18 expired sealed plastic bags of Secondary Administration Sets, one sealed plastic bag of Dressing Change Tray, one plastic bag of Foley Catheter Insertion Tray, and four Pivodon-Iodine Swab sticks, all of which were expired. Interviews with staff revealed that the nurses working on the medication carts were responsible for discarding expired medications from the medication storage room. However, Nurse #6 admitted that she had not checked the expiration date of medications at the beginning of her shift. The Director of Nursing (DON) and the Administrator both indicated that all nurses were responsible for checking and removing expired medications and supplies every shift, and they expected no expired items to be left in the medication storage room.
Failure to Administer Influenza and Pneumonia Vaccines
Penalty
Summary
The facility failed to administer the influenza and pneumonia vaccines to two residents who had signed consent forms for these vaccinations. Resident #33, who had moderate cognitive impairment, was admitted to the facility and had a consent form signed by their responsible party on 12/29/23. Despite the consent, there was no record of Resident #33 receiving the influenza or pneumonia vaccines. Similarly, Resident #54, who was cognitively intact, had a consent form signed on 01/17/24, but there was no documentation of the resident receiving the vaccines either. Both residents had signed consents indicating they were to receive the vaccines annually unless medically contraindicated, but the facility failed to follow through with the administration of these vaccines. Interviews with the Infection Preventionist and the Director of Nursing (DON) revealed that both were relatively new to their positions and were unaware of why the vaccines were not administered. The Infection Preventionist had recently audited the vaccinations and was preparing to obtain consents and administer the vaccines, while the DON confirmed that residents should have received the vaccines once the consent was signed. However, neither could provide an explanation for the oversight in administering the vaccines to Resident #33 and Resident #54.
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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 Greensboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Grove Health And Rehabilitation Center | 1.4 mi | ★★★★★ | 2 | 0 |
| Kindred Hospital East Greensboro | 2.9 mi | ★★★★★ | 7 | 0 |
| Guilford Health Care Center | 3.1 mi | ★★★★★ | 5 | 0 |
| Whitestone A Masonic And Eastern Star Community | 3.4 mi | ★★★★★ | 0 | 0 |
| Piedmont Hills Center For Nursing And Rehab | 3.8 mi | ★★★★★ | 14 | 0 |
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