Greenway Health and Rehabilitation Center, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, residents record review, review of a facility policy titled Abuse, Neglect and Exploitation, review of a Facility Reported Incident (FRI), and review of the facility's investigative file, the facility failed to ensure Resident Identifier (RI) #33 and RI #42 did not physically abuse each other. Specifically, On 04/08/2025 staff failed to provide supervision and intervene when RI #33 was upset and yelling out at RI #42. As RI #42 passed by RI #33, RI #33 hit RI #42, which resulted in RI #42 hitting RI #33 back. According to RI #33's plan of care when RI #33 had acute behaviors staff should intervene promptly to reduce the risk of escalation. This deficiency was cited as the result of the investigation of complaint/report number AL00051008. Findings Include: Review of an undated facility's policy titled, Abuse, Neglect and Exploitation, revealed the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and review of facility policies titled,OnTray Dietary Policies and Procedures, Use-By Guideline Handout, Ice Machine: Bin Type and Scoop, Hood, Vents & Filter the facility failed to ensure: 1) food items in the freezer were labeled; 2) the ice machine was cleaned and; 3) the stove hood bulbs and stove hood was free of a a grease like substance. This had the potential to affect 63 of 63 residents who received meals from the kitchen. Findings including: A review of a facility's policy titled, Use-By Guidelines Handout with no date revealed: The following guide can be used to determine a use-by date when labeling opened or unopened food that must be used within a certain time frame. Foods with a manufacturer's use-by date should still require an opened-on date once the item is opened. On 04/02/2025 at 8:33 AM, the surveyor and the Dietary Director (DD) #27 toured the kitchen. The surveyor and the DD observed diced potatoes frozen in a large bag, six hamburger patties in a large bag, chicken thighs in a large bag, about sixty potatoes tarts in a large…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and review of a facility policy titled OnTray Dietary Policies and Procedure, the facility failed to ensure the dumpster doors were closed on dumpsters one and two. This had the potential to affect 65 of 65 residents who reside at the facility. Findings include: A review of an undated facility policy titled, OnTray Dietary Policies and Procedure, revealed: Trash Disposal . Purpose: To prevent the spread of infection and deter pests and rodents. 2. The dietary department should ensure the dumpster lids are closed when disposing of trash . On 04/02/2025 at 9:09 AM, the surveyor toured the dumpster area with the Dietary Director (DD) #27. The dumpster door on one and two dumpsters were opened on the side. The opened dumpster doors were facing each other. On 04/04/2025 at 9:45 AM the DD said, she saw the dumpster and she stated the two dumpster doors facing each other were opened. The DD stated, staff did not close them. The DD stated, all staff in the building were responsible for keeping the dumpster doors closed to keep out rodents, pests, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview and Payroll Based Journal (PBJ) Report, the facility failed to report accurate staff data from Fiscal Year (FY) Quarter 1 (October 1 to December 31) to the Center of Medicare and Medicaid Services (CMS). This affected one quarter of data reviewed during the survey and had the potential to affect all 65 residents in the facility. Findings Include: The PBJ report generated for the quarter October 1-December 21, 2023, documented: . This Staffing Data Report identifies areas of concern that will be triggered . Excessively Low Weekend Staffing . Triggered . Submitted Weekend Staffing data is excessively low . On 04/08/2025 at 4:14 PM a telephone interview was conducted with the Director of Informatic (DI). The DI stated she was responsible for submitting the PBJ to CMS. She sated the previous ownership submitted the PBJ for the first part of the quarter and she submitted part of the PBJ for 11/16/2024 to 12/31/2024. When asked why the facility triggered for excessively low weekend staff, she stated because the facility's time and attendance system…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, the facility's investigative file, a review of information from the Alabama Department of Public Health's (ADPH) Online Reporting System, the facility policies titled ABUSE POLICY/REPORTING ABUSE, and Medication Administration the facility failed to ensure Resident Identifier (RI) #324 and RI #329 were free from misappropriation of property when the resident's controlled substances were unable to be accounted for after Licensed Practical Nurse (LPN) #31's shift from 6:00 PM on 07/14/2024 to 6:00 AM on 07/15/2024. Specifically, LPN #31 signed RI #324's Controlled Drug Record for Lorazepam indicating that she removed a tablet. RI #324's Medication Administration Record (MAR or EMAR) revealed that the medication was not administered. During medication count back of LPN #31's cart, one of RI #329's Gabapentin was missing and was not documented as administered on RI #329's MAR. This deficient practice affected Resident Identified (RI) #324 and RI #329, two of 19 residents reviewed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, the Alabama Department of Public Health Online Incident Reporting System, review of a facility investigative file, and review of a facility policies titled ERRORS IN CONTROLLED SUBSTANCE COUNTS / DISCREPANCIES and Medication Administration the facility failed to ensure Licensed Practical Nurse (LPN) #31 followed standard of practice when she failed to document the administration of controlled medications during the 6:00 PM (07/14/2024) to 6:00 AM (07/15/2024) shift per facility's policy and standards of practice. Specifically, LPN #31 failed to document the removal of controlled medications on the residents' Controlled Drug Records when she documented the medications as administered on the Electronic Medication Administration Record (EMAR or MAR). The deficient practice affected Resident Identifiers (RI) # 6, RI #20, RI #327, RI #328, RI #319. Further, LPN #31 failed to administer RI #319's Norco on 07/15/2024 at 1:00 AM, RI #22's Gabapentin on 07/14/2024 at 8:00 PM, and RI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of the Center for Medicare and Medicaid (CMS Center) Long-Term Care Resident Instrument 3.0 Manual, the facility failed to ensure Resident Identifier (RI) #53's Minimum Data Set (MDS) assessment dated [DATE] was coded accurately to reflect RI #53 had a Preadmission screening and Resident Review (PASRR) Level II. This deficient practice affected one of 20 sampled residents whose MDS was reviewed. Findings include: Review of Center for Medicare and Medicaid (CMS) Long- Term Care Resident Instrument 3.0 Manual, dated October 2024, revealed the following: A 1500 Preadmission Screening and Resident Review (PASRR) . Code 1. Yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition. RI #53 was admitted to the facility on [DATE] and had diagnoses to include Depression, Adjustment Disorder with Mixed Disturbances of Emotions and Conduct, and Psychotic Disorder with Delusions due to known Physiological Condition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and review of facility policies titled, DAILY CATHETER CARE MALE/FEMALE and FEEDING RESIDENTS, the facility failed to ensure: 1) Resident Identifier (RI) #4's Foley GU (Genitourinary) bag was in a dignity bag on 10/03/2023 when out of his/her room; and 2) staff did not stand while feeding RI #9 the lunch and dinner meals on 10/03/2023. These deficient practices affected RI #4, one of three residents, sampled with GU bags; and RI #9, one of two sampled residents requiring assistance with meals. Findings include: 1) A facility policy titled, DAILY CATHETER CARE MALE/FEMALE, dated 04/2023, revealed the following: . When policy applies At all times . • Cover catheter bag with dignity bag at all times . RI #4 was admitted to the facility on [DATE] with a diagnosis of Retention of Urine. RI #4's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 09/18/2023, revealed RI #4 had an indwelling catheter during this assessment period. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and review of policies titled, FOOD STORAGE and Food Storage from Visitors or Family the facility failed to ensure: 1. opened, stored food items in the kitchen were labeled appropriately during the initial kitchen observation on 7/10/2022. This had the potential to affect all 68 residents that receive meals from the kitchen. 2. the unit refrigerators were not found with unlabeled food items on 7/12/2022. This had the potential to affect all 71 residents residing at the facility who could have had food items stored in the unit refrigerators. Findings include: Review of an undated facility policy titled, FOOD STORAGE revealed, Policy Statement . PROCEDURES . 15. a. All opened, refrigerated items should possess an opened date and used by date. Review of a facility policy titled, Food Storage from Visitors or Family with a last review date of 5/2022 revealed, . PROCEDURE When food is brought in from outside for a resident the following will occur: Food is taken by the front desk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews and review of facility policies titled, Activities of Daily Living and Care Plan Initiation, the facility failed to ensure staff followed the plan of care regarding assistance with Activities of Daily Living (ADL) care for (Resident Identifier) RI #7 and RI #30. This had the potential to affect RI #7 and RI #30, two of eighteen residents whose care plans were reviewed. Findings include: 1. A review of a facility policy titled, Activities of Daily Living (ADLs) with a last review date of 5/2022, revealed, Who should follow the policy All Staff When policy applies At all times . Provide care and offer assistance to resident during ADLs . Follow the care plan designed for each resident . ADLS include but not limited to the following types of care: . Body care . RI #7 was readmitted to the facility 4/12/2022. Review of RI #7's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed RI #7 had a Brief Interview for Mental Status (BIMS) Score of five…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and review of facility policies titled, Activities of Daily Living, TO ASSURE QUALITY RESIDENT CARE AND CONTINUITY OF RESIDENT CARE and Grooming Facial Hair for Male and Female Residents, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided to Resident Identifier (RI) #7 and RI #30, two of two residents sampled for the provision of ADL care. Findings include: A review of a facility policy titled, TO ASSURE QUALITY RESIDENT CARE AND CONTINUITY OF RESIDENT CARE, with a last review date of 5/2022 revealed, Who should follow the policy All Staff When policy applies At all times . PROVIDE RESIDENT CARE ASSIGNMENTS . PERSONAL CARE . SHAVING . A review of a facility policy titled, Grooming Facial Hair for Male and Female Residents, last updated 4/2022, revealed, Who should follow the policy All Staff When policy applies At all times . PROCEDURE Grooming of facial hair for a male or female resident will be as follows: . Resident's facial hair will be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of Resident Identifier (RI) #9's medical record, the facility failed to ensure the resident, their representative and the Office of the State Long-Term Care (LTC) Ombudsman received written notification of RI #9's transfer/discharge to a local hospital. This deficient practice affected RI #9; one of two sampled residents reviewed for hospitalization. Findings include: RI #9 was admitted to the facility on [DATE]. According to RI #9's medical record, the resident was transferred/discharged to a local hospital on [DATE], 11/20/2020, 12/10/2020, 1/25/2021, 4/24/2021, 5/4/2021, and 5/28/2021. There was no documentation found within the resident's medical record of a written notification to the resident, the resident's representative, or the Office of the State LTC Ombudsman regarding either transfer/discharge to the local hospital for RI #9. On 6/9/2021 at 5:53 PM, an interview was conducted with Employee Identifier (EI) #1, the Administrator and EI #2, the Social Service Director. Both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of Resident Identifier (RI) #9's medical record, the facility failed to issue a bed-hold notice to the resident and/or their representative when RI #9 was transferred to a local hospital. This deficient practice affected RI #9; one of two sampled residents reviewed for hospitalization. Findings include: Review of the facility admission Packet revealed a section titled Transfer and Discharge that stated We will not transfer a resident to a hospital or allow a resident to go on therapeutic leave without first providing written information to that resident and a family member or legal representative specifying the applicable bed hold policy. Bed hold policy refers to the period of time (if any) during which the resident is permitted to return and resume residence in the facility after hospitalization or therapeutic leave. RI #9 was admitted to the facility on [DATE]. According to RI #9's medical record, the resident was transferred to a local hospital on [DATE], 11/20/2020, 12/10/2020,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and review of Resident Identifier (RI) #15's medical record, the facility failed to provide feeding assistance to RI #15, a resident assessed as being totally dependent on staff for eating. This deficient practice affected RI #15; one of four sampled residents reviewed for nutrition. Findings include: RI #15 was admitted to the facility on [DATE]. A review of RI #15's medical record revealed on 1/19/2021, the resident weighed 210.6 pounds. RI #15's Significant Change in Status Minimum Data Set (MDS) with an assessment reference date of 3/3/2021 indicated the resident was totally dependent on the staff for eating. The MDS listed RI #15 as having a weight of 203 pounds during this assessment period. A review of RI #15's medical record indicated on 3/21/2021, the resident was ordered a pureed diet with nectar thick liquids. A review of RI #15's medical record revealed on 6/2/2021, the resident weighed 214 pounds. During lunch meal observations on 6/7/2021 at 12:53 PM and 6/8/2021 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.