Greenwood Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure food was not stored beneath a water line on which water had condensed for 2 of 2 observations of the kitchen freezer. Findings include: During a tour of the facility's walk-in freezer, on 6/24/25 at 2:15 p.m. and 7/1/25 at 10:30 a.m., food was observed to be stored beneath the freezer condenser water line, upon which water had condensed and ice had formed. Beneath the freezer condenser were three boxes of cookie dough, two boxes of pizza dough, and two boxes of dinner rolls. Ice had fallen from the frozen condenser line onto the boxes. During an interview on 6/24/25 at 10:35 a.m., the Dietary Manager indicated there was ice formed on the leaking condenser and food was stored beneath the condenser. During an interview on 6/24/25 at 10:45 a.m., the facility Administrator indicated the facility used the Indiana State Department of Health Retail Food Establishment Sanitation Requirements, effective date, November 13, 2004, as the facility policy and procedure regarding food storage. A review of the policy…

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 the resident's representative and physician were notified of significant weight loss for 2 of 7 residents reviewed for nutrition. (Resident 5, Resident 85) Findings include: 1. During an observation on 6/26/25 at 10:09 a.m., Resident 5 was observed to be eating a snack. During an observation on 6/26/25 at 12:37 p.m., Resident 5 was observed to be feeding herself a pureed diet. During an observation on 6/30/25 at 1:02 p.m., Resident 5 was observed to be feeding herself. On 6/26/25 at 11:05 a.m., Resident 5's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, and anemia. The Weights and Vitals Summary indicated the following: - On 5/6/25 at 4:05 p.m., Resident 5's weight was 111 pounds. - On 6/6/25 at 3:42 p.m., Resident 5's weight was 102 pounds. This was 8.11% weight loss in one month. The care plan, dated 1/29/25, indicated Resident 5 had altered nutritional status due to Alzheimer's disease and dementia. The intervention was to notify medical…

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 the accuracy of the Minimum Data Set (MDS) assessment for 2 of 32 residents reviewed for accuracy of the MDS assessments. (Resident 12, Resident 152) Findings include: 1. On 6/26/25 at 11:52 a.m., Resident 12's clinical record was reviewed. The diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (a progressive lung disease that makes it hard to breathe due to airflow blockage), dysphagia (difficulty swallowing), and dementia (a decline in mental ability severe enough to interfere with daily life). A review of the Discharge MDS assessment, dated 6/18/25, did not indicate the resident had a significant weight loss (5% or more in the last 30 days or 10% or more in the last 180 days), in section K0300: Weight Loss. A review of a dietary progress note, dated 6/14/25, indicated Resident 12 had a significant weight loss in the last 180 days. The resident had a 16.8% weight loss in 90 days and a 10% weight loss in 180 days. During an interview with the MDS Coordinator on 7/1/25 at 10:55 a.m.,…

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 the care plan was revised for 1 of 4 residents reviewed for accidents. (Resident 92) Finding include: During an observation on 6/26/25 at 12:20 p.m., Resident 92 was observed to be ambulating with her walker. The walker was observed not to have bright colored tape on it. During an observation on 6/26/25 at 2:03 p.m., Resident 92 was observed to be ambulating with her walker. The walker was observed not to have bright colored tape on it. During an observation on 6/27/25 at 12:04 p.m., Resident 92 was observed to be resting in bed with the walker at bedside. The walker was observed not to have bright colored tape on it. During an observation on 6/30/25 at 10:13 a.m., Resident 92 was observed to be ambulating with her walker. The walker was observed not to have bright colored tape on it. During an observation on 6/30/25 at 12:38 p.m., Resident 92 was observed to be in the dining room with her walker. The walker was observed not to have the bright colored tape on it. On 6/26/25 at 2:28 p.m., the clinical…

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 staff provided the services for a resident to maintain good personal hygiene (Resident 109) for 1 of 1 resident reviewed for Activities of Daily Living (ADLs). Finding includes: During an interview on 6/24/25 at 3:16 p.m., Resident 109's toenails were observed to be very long in length and thick in texture. He indicated they were bothering him and he needed them clipped by someone because he could not reach his feet. On 6/27/25 at 11:06 a.m., Resident 109's toenails were observed to be very long in length and thick in texture. On 6/25/25 at 10:02 a.m., Resident 109's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, morbid (severe) obesity, and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment, dated 4/13/25, indicated the resident was cognitively intact. A 10/15/23 physician's order, indicated the resident was ordered podiatry consults as needed. The resident's clinical record lack documentation the resident had received podiatry services.…

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 protect the resident's rights to be free from physical abuse by a staff member for 1 of 3 residents reviewed for abuse. A staff member held down the residents arms to provide care. (Resident B, CNA 1) Finding includes: During an interview on 2/7/25 at 10:30 a.m., the Administrator (ADM) indicated CNA 1 was recently terminated for physically holding down Resident B's wrists/arms during resident care. She indicated Resident B had become combative during care and the CNA held down Resident B's limbs to prevent an injury to herself. On 2/7/25 at 10:45 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, and anxiety disorder. The Quarterly Minimum Data Set assessment, dated 12/26/24, indicated Resident B had severe cognitive impairment. A progress note, dated 1/23/25 at 12:00 p.m., indicated the resident was receiving care and the hospice aid became concerned with the CNA's technique. During an interview on 2/7/25 at 12:00 p.m., CNA 1 indicated 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 record review and interview, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and/or the resident representative for 4 of 4 residents reviewed for hospitalization and discharge. (Resident 96, Resident 148, Resident 145, and Resident 160) Findings include: 1. On 8/9/24 at 1:00 p.m., Resident 96's clinical record was reviewed. The diagnoses included, but were not limited to, opioid dependence and acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). Residents 96's transfer forms indicated the resident was sent to the hospital on 5/12/24 and 6/23/24. The clinical record lacked documentation of written Notice of Transfer and Discharge forms having been provided to the resident and/or the resident representative. 2. On 8/12/24 at 2:27 p.m., Resident 148's clinical record was reviewed. The diagnoses included, but were not limited to, asthma, tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the trachea…

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 the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 4 of 4 residents reviewed for hospitalization and discharge. (Resident 96, Resident 148, Resident 145, and Resident 160) Findings include: 1. On 8/9/24 at 1:00 p.m., Resident 96's clinical record was reviewed. The diagnoses included, but were not limited to, opioid dependence and acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). Residents 96's transfer forms, indicated the resident was sent to the hospital on 5/12/24 and 6/23/24. The clinical record lacked documentation of written notification of the bed-hold policy having been provided to the resident or the resident representative. 2. On 8/12/24 at 2:27 p.m., Resident 148's clinical record was reviewed. The diagnoses included, but were not limited to, asthma, tracheostomy (procedure to help air and oxygen reach the lungs by creating…

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 could self-administer medication for 1 of 1 randomly observed resident (Resident 38). Finding include: On 8/7/24 at 2:41 p.m., Resident 38 was observed to be resting in her bed. A bottle of Tums (antacid) was observed to be on her bedside table. On 8/8/24 at 11:15 a.m., Resident 38 was observed to be resting in her bed. A bottle of Tums was observed to be on her bedside table. On 8/12/24 at 10:58 a.m., Resident 38 was observed to be resting in bed with a bottle of Tums lying in bed beside her. On 8/12/24 at 11:37 a.m., Resident 38's clinical record was reviewed. The diagnoses included, but were not limited to, end stage renal disease (ESRD) and gastro-esophageal reflux disease (GERD). The Self Administration of Medication Assessment, dated 10/14/22 at 12:20 p.m., indicated Resident 38 could administer Halls throat lozenges. The Order Summary Report, dated 8/12/24, lacked a physician order for Tums or to self-administer medication. The care plan lacked a care plan to self-administer…

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 residents were provided an adequately lit, homelike environment for 1 of 7 units reviewed for environmental concerns. (Unit G) On the following dates and times the main hallway of the secured Unit G was observed to have dim, flickering overhead fluorescent lights, and dark colored walls void of homelike decor or adornment: - On 8/6/24 at 12:35 p.m. - On 8/6/24 at 2:40 p.m. - On 8/7/24 at 10:40 a.m. - On 8/7/24 at 12:50 p.m. - On 8/7/24 at 3:05 p.m. - On 8/8/24 at 9:28 a.m. - On 8/8/24 at 2:26 p.m. - On 8/9/24 at 12:27 p.m. - On 8/9/24 at 3:10 p.m. - On 8/12/24 at 9:45 a.m. - On 8/12/24 at 12:05 p.m. Confidential interviews were conducted during the course of the survey from 8/6/24 through 8/12/24. These interviews indicated the secured Unit G was consistently dimly lit with flickering overhead fluorescent lights. The hallway walls were dark and lacked decor indicative of a homelike environment. During an interview on 8/12/24 at 12:15 p.m., the Administrator indicated the main hallway of the secured…

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 accurate reconciliation and accounting for narcotics (controlled medications) were performed for 2 of 3 shifts reviewed. (LPN 2, LPN 3, RN 4) Findings include: On 3/26/24 at 9:00 a.m., Resident D's clinical record was reviewed. Resident D's physician orders included, but were not limited to, oxycodone (narcotic/controlled pain medication) 5 mg (milligrams) every 8 hours as needed for pain, started on 2/22/24 and discontinued on 2/23/24. The February Medication Administration Record (MAR) indicated Resident D had not received any oxycodone pain medication during the month of February. During an interview on 3/26/24 at 10:05 a.m., the Assistant Director of Nursing Services (ADNS) indicated the facility Controlled Drug Administration Record reflected no oxycodone were administered to Resident D. Additionally, the 30 oxycodone tablets were missing from the narcotic box. The number of tablets in the lock box and paper document should have matched. During an interview on 3/26/24 at 10:20 a.m., the ADNS indicated 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, interview, and record review, the facility failed to ensure medications were not left at bedside without a self medication administration assessment for 1 of 1 random observations.(Resident 79) Finding includes: During an interview on 6/27/23 at 11:30 a.m., with Resident 79, a medicine cup full of pills was observed to be sitting on the bedside table. The resident indicated the nurse dropped them off that morning and had not left any water nor had she split the potassium in half as required by the resident to swallow the pill. During an interview on 6/27/23 at 11:45 a.m., Licensed Practical Nurse (LPN) 1 indicated she should have stayed with Resident 79 to watch her take the morning medications. LPN 1 indicated Resident 79 was not assessed to self administer medications. Resident 79's clinical record was reviewed on 6/27/23 at 11:50 a.m. The diagnoses included, but were not limited to, Multiple Sclerosis (MS) and peripheral vascular disease. Current physician orders, dated June, 2023, indicated Resident 79's medications included, but were not limited to: -…

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 Minimum Data Set (MDS) assessments accurately reflected resident status for 3 of 3 residents reviewed for accuracy of assessments. Level 2 PASRR (Preadmission Screening and Resident Review) and discharge status were coded incorrectly. (Resident 25, Resident 38, Resident 166) Findings include: 1. On 6/30/23 at 11:40 a.m., Resident 25's clinical record was reviewed. The diagnoses included, but were not limited to, bipolar disorder and major depressive disorder. The Level 2 PASRR, dated 7/19/21 indicated, You meet PASRR criteria based on your diagnoses, current symptoms, and treatment needs including recent medication management. The Annual MDS assessment, dated 9/23/22, indicated, Has the resident been evaluated by level 2 PASRR and determined to have a serious mental illness and/or mental retardation or related condition .no. 2. On 6/30/23 at 11:50 a.m., Resident 38's clinical record was reviewed. The diagnoses included, but were not limited to, schizoaffective disorders and dementia. The Level 2 PASRR, dated…

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 a care plan was in place for a resident who was diagnosed with a urinary tract infection for 2 of 2 residents reviewed for urinary tract infections. (Resident 34, Resident 151) Findings include: 1. Resident 34's clinical record was reviewed on 6/30/23 at 11:00 a.m. The diagnosis included, but was not limited to, adult failure to thrive. Current physician orders, dated June 2023, indicated Resident 34 was taking amoxicillin-pot clavulanate (an antibiotic) tablet 875-125 milligrams 1 tablet by mouth every 12 hours for Extended Spectrum Beta-Lactamase (ESBL) in the urine. The start date was 6/23/23. The Infection Surveillance Criteria Report, dated 6/29/23, indicated Resident 34 was diagnosed with a urinary tract infection (UTI). A lab report, dated 6/22/23, indicated Resident 34 had greater than 100,000 escherichia coli ESBL which indicated the resident had a UTI. A review of the care plans on 6/30/23 at 12:00 p.m., for Resident 34 lacked documentation of a current care plan for a urinary tract infection. 2. During an…

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.