Greenwood Health And Living Community

Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 3 of 3 kitchen observations. Staff hair was not covered while in the kitchen food preparation area and while serving the meal. (Dietary Aide 2 and Dietary Aide 3) Finding includes:1. During the initial kitchen observation with [NAME] 4 on 4/12/26 from 9:10 a.m. to 9:20 a.m., the following was observed: - Dietary Aide 2 was observed walking through the kitchen area. Dietary Aide 2 was observed to have facial hair, above and below the lip area and along the jaw line, that was approximately one fourth inch in length. The facial hair was observed to not be covered.- Dietary Aide 3 was observed walking through the kitchen area. Dietary Aide 3 was observed to have facial hair above the lip area that was approximately one fourth inch in length. The facial hair was observed to not be covered.2. During a follow-up kitchen observation on 4/12/26 from 11:58 a.m. to 12:10 p.m., the following was observed:- Dietary Aide 2 was observed walking through the kitchen…

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, interview, and record review, the facility failed to ensure a self- administration medication assessment was completed for residents with medications left at bedside for 1 of 32 residents rooms observed. (Resident 30) Finding includes: During initial tour on 4/12/26 at 9:22 a.m., observed Resident 30's room. Resident 30 was sitting up in the wheelchair. Resident 30 had an overbed table. A handheld Albuterol (a medication used to treat asthma and chronic obstructive pulmonary disorder symptoms) inhaler 90 mcg (micrograms). No staff were observed to be in the room or in hallway. On 4/13/26 at 8:31 a.m., Resident 30 sitting up in the wheelchair and indicated that his Albuterol inhaler was in his top drawer of his nightstand. Inside the drawer the Albuterol inhaler was observed. On 4/13/26 at 8:40 a.m., Resident 30's clinical record was reviewed. An admission Minimum Data Set (MDS) assessment, dated 3/2/26, indicated Resident 30 had no cognitive impairment. Resident 30's clinical record lacked a self-medication administration assessment. During an interview 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 interview and record review, the facility failed to protect the resident's rights to be free from misappropriation of property for 5 of 5 residents reviewed for misappropriation of property. Narcotic medications were missing. (Resident B, Resident C, Resident D, Resident E, Resident F) Findings include: 1. On 5/20/25 at 12:02 p.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, hypertensive chronic kidney disease and osteomyelitis of vertebra (inflammation of bone caused by infection of a spinal disc). The Annual MDS (Minimum Data Set) assessment, dated 4/7/25, indicated Resident B was cognitively intact. The Physician's Orders included, but were not limited to: - Hydrocodone-acetaminophen (narcotic pain medication) 5-325 mg (milligrams), every six hours a day for pain, initiated 3/27/24. 2. On 5/20/25 at 12:05 p.m., Resident C's clinical record was reviewed. The diagnoses included, but were not limited to, osteomyelitis, pneumonia, and acute respiratory…

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, interview, and record review, the facility failed to develop care plans for 5 of 19 residents reviewed. Care plans were not developed for skin conditions, use of an electric wheelchair, and non-compliance. (Resident F, Resident 28, Resident 73, Resident 56, Resident 74) Finding includes: 1. On 5/20/25 at 8:30 a.m., observed Resident F in the hallway. Resident F was observed sitting in his manual wheelchair in the hall way. Resident F was wearing short pants. Multiple dried scabs were noted on his bilateral lower extremities. An open area was observed on his left knee and no dressing was observed. During an interview on 5/20/25 at 9:30 a.m., Resident F indicated the facility took his electric wheelchair away from him. On 5/20/25 at 10:00 a.m., Resident F's clinical record was reviewed. The diagnoses included, but were not limited to, physical debility and muscle weakness. An admission Assessment, dated 4/21/25, indicated Resident F arrived to the facility with a motorized wheelchair. An admission Minimum Data Set (MDS) assessment, dated 4/28/25, indicated…

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, interview and record review, the facility failed to provide reasonable accommodation of needs for 1 of 19 reviewed for call light access. (Resident 73) Finding includes: On 5/20/25 from 8:35 a.m. to 8:40 a.m., Resident 73 was observed resting in bed while eating breakfast. Resident 73's call light was observed approximately 3 feet to the left of the head of the bed. The call light cord and mechanism were observed hanging from the wall to approximately 3 inches above the floor. The observed call light system was not within reach of the resident. During an interview at that time, Resident 73 indicated he did not know where the call light was located. During an interview on 5/20/25 at 8:43 a.m., Scheduler 7 indicated Resident 73's call light was to be kept within reach of the resident. Resident 73 sometimes would throw his call light around. On 5/22/25 at 8:45 a.m., Resident 73 was observed sitting in his wheelchair that was positioned at the foot end on the left side of the bed. Resident 73 was facing away from the head of the bed. Against the wall and to the…

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, record review, and interview, the facility failed to provide care in accordance with the plan of care for 1 of 1 residents reviewed for skin conditions. Physician's orders were not followed for skin treatments. (Resident F) Finding includes: On 5/20/25 at 8:30 a.m., observed Resident F in the hallway. Resident F was observed sitting in his wheelchair in the hall way. Resident F was wearing short pants. Multiple dried scabs were observed on both of his legs. An open area was observed on his left knee. No dressing was observed. On 5/21/25 at 9:00 a.m., observed Resident F in the hallway wearing short pants. Multiple dried scabs were observed on his both of his legs. An open area was observed on his left knee. No dressing was observed. On 5/22/25 at 9:18 a.m., Resident F was observed sitting in the hallway in his wheelchair wearing shorts. Dried red drainage was observed on his left leg. Open area's on both legs and his left knee were observed to be exposed. On 5/23/25 at 9:48 a.m., Resident F's clinical record was reviewed. The diagnosis included, but was not…

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, interview, and record review, the facility failed to ensure a resident's enteral feeding (tube feeding) was signed and dated for 1 of 1 resident reviewed for enteral feeding devices. (Resident 253) Finding includes: On 5/19/25 at 11:45 a.m., Resident 253's clinical record was reviewed. The diagnoses included, but were not limited to, atherosclerotic heart disease (a build-up of plaque in artery walls) and unspecified dysphagia (difficulty swallowing). Physician's Orders indicated Resident 253 had an order for Osmolite 1.2 (a type of enteral tube feeding) to run at 65 mL/hr (milliliters per hour) and H20 (water) at 53 mL/hr bolus (dose) to run continuously on each shift. On 5/19/25 at 12:45 p.m., Resident 253 was observed resting in bed. Next to the bed was an IV pole with an electronic pump device connected to Resident 253. The device was noted to be running at the time of observation. The tube feeding container running into the pump device was labeled as Osmolite 1.2 roughly three fourths full of a tan colored liquid and an unlabeled bag filled with clear…

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 interview and record review, the facility failed to ensure residents were provided a two-step tuberculin skin test upon admission for 1 of 5 resident reviewed for tuberculin skin tests. (Resident 50) Finding includes: On 5/19/25 at 12:45 p.m., Resident 50's clinical record was reviewed. The diagnoses included, but were not limited to, chronic respiratory failure, chronic pulmonary edema (an abnormal build up of fluid in the lungs), and type 2 diabetes mellitus (a chronic condition causes high blood sugar levels). Resident 50 had an admission date of 3/29/25. Resident 50's TB (Tuberculin) test administration history indicated that resident had a first step TB skin test administered on 3/29/25 and a first step TB skin test administered on 4/30/25. The two skin tests were each read with negative results and they were administered 32 days apart. Both tests were labeled in the system as first step TB skin tests and there was no timely second step associated with either. During an interview on 5/22/25 at 9:00 a.m., the DON (Director of Nursing) indicated that Resident 50's two…

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 record review, the facility failed to protect the resident's rights to be free from misappropriation of property for 1 of 1 allegation of misappropriation of property. (Resident B) Finding include: On 4/30/25 at 12:02 p.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, right tibia (shin bone) fracture, cellulitis, and pain in right leg. The annual MDS (Minimum Data Set) assessment, dated 3/7/25, indicated Resident B was cognitively intact. The Physician Order Report, dated 4/30/25, indicated the following: - Oxycodone-acetaminophen (pain medication) 7.5-325 mg (milligrams), twice a day for pain, initiated 1/13/25. - Oxycodone-acetaminophen 7.5-325 mg, every 4 hours as needed for right leg pain, initiated 1/13/25. Resident B's Controlled Drug Record for Oxycodone-acetaminophen 7.5-325 mg had a tablet signed out on 4/11/25 at 10:00 a.m. by Licensed Practical Nurse (LPN) 1. Four tablets remained. During an interview on 4/30/25…

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 observation, interview, and record review, the facility failed to develop a person-centered care plan for a resident with a hearing device for 1 of 1 residents reviewed with a hearing device. (Resident 42) Finding includes: On 5/8/24 at 11:03 a.m., Resident 42 was observed resting in bed. During an interview at that time, Resident 42 indicated she was not able to hear or understand what was being said because she was unable to find her amplifier device system (hearing assistance device). On 5/9/24 at 9:24 a.m., Resident 42 was observed resting in bed. Resident 42 was observed putting on a head-set which was attached to an amplifier system. During an interview at that time, Resident 42 indicated she relied on the amplifier device system to be able to hear. On 5/10/24 at 11:15 a.m., Resident 42 was observed resting in bed watching TV. Resident 42 was observed wearing a head-set which was attached to an amplifier device system. On 5/9/24 at 1:06 p.m., Resident 42's clinical record was reviewed. Diagnosis…

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 observation, interview, and record review, the facility failed to ensure medications were dated for 1 of 2 medication carts of observed. Insulin pens were not dated with an open date. (200 Medication Hall Cart) Findings include: During a medication storage and labeling review, on 5/9/24 at 9:25 a.m., observed 4 opened Insulin Flex Pens 100 units/ml (milliliter) in 200 Hall Medication Cart. The Flex Pens were not labeled indicating the date the Flex pens were opened. During an interview on 5/10/24 at 9:05 a.m., the Regional Nurse Consultant indicated the insulin pens on the cart should have been dated with an open date. On 5/9/24 at 10:15 a.m., the Director of Nursing provided a policy titled, Insulin Packaging G-24, from Policy and Procedure [NAME], undated, and indicated it was the current policy being used by the facility. A review of the policy indicated .1. When activating a bottle of insulin, remove the bottle from the box, Date the bottle, Retain the bottle for 28 days, then discard. 3.1-25(j)

Based on observation, interview, and record review, the facility failed to implement the plan of care for 4 out of 5 residents reviewed for falls. Call lights were not within reach. (Resident B, Resident C, Resident D, Resident E) Finding includes: 1. On 9/19/23 at 9:07 a.m., observed Resident B sitting in his wheelchair, in his room, watching television. Resident B's call light was observed attached to Resident B's pillow, on the bed, approximately 4 feet from Resident B. At that time, Resident B indicated if he needed assistance he would use the call light, but he could not reach the call light. Resident B was not able to propel his wheelchair on his own nor transfer and get to the bathroom without assistance because his leg was amputated. The clinical record for Resident B was reviewed 9/20/23 at 12:37 p.m. The diagnoses included, but were not limited to, acquired absence of right leg below the knee and abnormality of gait and mobility. A Brief Interview for Mental Status, dated 9/19/23, indicated Resident B was mildly cognitively impaired. A care plan, dated 9/18/23 and current…

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.