Inspection Reports for Greenview Nursing and Rehab

The facility failed to properly label and date food items in the walk-in refrigerator and freezer, and did not address visibly soiled air conditioning vents in the kitchen, which could pose a risk of food contamination and foodborne illness.

The facility failed to have a policy ensuring safe and sanitary storage, handling, and consumption of foods brought by visitors for 1 of 5 residents reviewed. Specifically, Resident #1's personal refrigerator was found with a brown substance and a food-encrusted butter knife, and lacked a temperature log, posing a risk of foodborne illness.

The facility failed to clean food debris and dead fly larvae (maggots) from Resident #1's bedside table, posing a potential infection control risk and creating an unclean environment. Interviews and record reviews revealed inconsistent cleaning practices and lack of monitoring for food hoarding in residents' drawers.

The facility failed to provide continuous one-to-one monitoring for Resident #1 after repeated aggressive behavior against Resident #2, resulting in an Immediate Jeopardy that was later removed but noncompliance remained. The facility also failed to ensure Resident #3 was not physically abused by a medication aide and failed to administer her prescribed Rivaroxaban medication on multiple dates, placing residents at risk of harm.

The facility was found deficient in providing appropriate pressure ulcer care, ensuring adequate supervision to prevent resident elopement and accidents, timely medication administration, maintaining a sanitary kitchen environment, and enforcing proper hand hygiene among staff.

The facility failed to ensure Resident #1's call light was within reach on 05/16/2025, placing residents at risk of unmet needs. Interviews with staff and the resident confirmed the call light was hanging approximately 2 feet away from the resident's wheelchair and was not clipped to him, despite policy requiring call lights to be accessible at all times.

The complaint investigation found that the facility did not report alleged physical abuse between Resident #1 and Resident #2 within 24 hours as required. The incident occurred on 04/05/2025 but was not reported to the State Survey Agency until 04/08/2025. Interviews revealed conflicting stories from the residents. The ADM acknowledged responsibility for the delayed reporting.

The facility failed to report alleged physical and verbal abuse incidents involving Resident #1 and Resident #2 to the State Survey Agency within the required 24-hour timeframe. Conflicting accounts were given by the residents, and the report to the state was delayed until three days after the incident occurred.

The facility was found deficient in multiple areas including failure to ensure call lights were within reach for residents, lack of private meeting space for resident council, inadequate grievance follow-up, failure to maintain resident privacy with medical records, unsafe and unsanitary living environment, improper psychotropic medication management, failure to obtain required hospice documentation, and food safety violations including improper food storage and poor hand hygiene during food distribution.

The complaint involved allegations of resident-on-resident abuse between Resident #1 and Resident #2 on 8/18/2024 and between Resident #1 and Resident #3 on 8/22/2024. The facility failed to report the first incident within the required 2-hour timeframe and did not update the care plan to prevent further incidents. The second incident was reported timely. Interviews with staff revealed lack of reporting and care plan updates. The Administrator acknowledged the decision not to report the first incident was his choice and did not believe interventions would have prevented the second incident.

The facility failed to prevent resident-on-resident abuse on two occasions involving Resident #1 physically abusing Resident #2 on 8/18/2024 and Resident #3 on 8/22/2024. The facility also failed to timely report the abuse incident involving Resident #1 and Resident #2 within the required 2-hour timeframe and failed to update Resident #1's Comprehensive Care Plan (CCP) after the first incident to prevent further occurrences.

The facility failed to ensure consistent phone service for residents, potentially impacting communication with family and providers. Additionally, the facility did not ensure two residents received scheduled showers, risking hygiene decline and skin issues.

The facility failed to maintain an adequate infection prevention and control program, as medical assistants did not properly clean and disinfect the wrist blood pressure monitor between use on multiple residents, potentially placing residents at risk of disease transmission. Interviews revealed gaps in staff knowledge and training regarding sanitization protocols.

The complaint investigation found that Resident #1 frequently refused dialysis treatments, and the facility did not notify the kidney center despite multiple missed appointments. The kidney center attempted to contact the facility several times without response. The resident was hospitalized due to complications from missed dialysis. The facility acknowledged phone issues but lacked documentation of attempts to notify the kidney center. Staff interviews confirmed expectations for notification and care planning were not met.

The facility failed to include measurable objectives and timeframes in the care plan addressing Resident #1's refusal of HD and did not notify the kidney center on multiple occasions when the resident missed dialysis appointments. This resulted in the resident being hospitalized due to volume overload and hyperkalemia after missing several HD sessions. Interviews with staff and the resident confirmed these failures and the lack of documentation and communication with the dialysis center.

The investigation was triggered by a complaint regarding Resident #1's decline in health, including severe dehydration and rhabdomyolysis. The complaint was substantiated by findings that the facility failed to monitor and address nutritional and hydration needs, failed to notify appropriate parties of the resident's decline, and lacked proper policies and documentation.

The facility failed to immediately inform the resident, physician, and family of significant changes in Resident #1's condition, failed to monitor and document nutritional and hydration intake adequately, and lacked a hydration policy. Resident #1 was hospitalized with severe dehydration and rhabdomyolysis after a decline in health while at the facility. Staff interviews and record reviews revealed inadequate care planning and communication regarding the resident's nutritional and hydration needs.

The complaint investigation focused on three residents (#1, #2, and #3). Resident #1 suffered a fall on 4/15/2024 resulting in a facial injury and subsequent death after being taken off life support. The facility failed to report this incident timely. Residents #2 and #3 were involved in a resident-on-resident abuse incident on 4/03/2024, which was not reported or investigated appropriately. The facility also failed to report the results of investigations within the required 5 working days.

The facility failed to timely report alleged abuse and neglect incidents involving three residents, including a fall resulting in a fatal injury and a resident-on-resident abuse incident. Additionally, the facility failed to thoroughly investigate and report the results of abuse allegations within the required timeframe, potentially placing residents at risk.

The facility failed to properly seal food products in airtight containers, label food products with product name and open/discard dates, and dispose of expired food. Additionally, the kitchen's only industrial can opener, food preparation areas, and dishwasher area were not adequately cleaned and sanitized, placing residents at risk of ingesting food-borne pathogens.

The complaint investigation was substantiated with findings that Resident #1 sustained 2nd degree burns due to the facility's failure to properly supervise and assist with hot liquids. Immediate jeopardy was identified on 01/11/2024 and removed on 01/12/2024, but the facility remained out of compliance at a severity level of actual harm and isolated scope while monitoring the plan of removal.

The facility failed to ensure adequate supervision and assistive devices for Resident #1, resulting in the resident sustaining 2nd degree burns from spilled hot coffee. The investigation revealed missing coffee temperature logs prior to January 2024, inconsistent temperature monitoring, and lack of staff awareness about hot liquid safety protocols. A plan of removal was implemented to address these issues, including staff education, monitoring of coffee temperatures, and updated care plans for residents at risk.

The complaint investigation focused on the facility's refusal to allow RES #6 to return after hospitalization despite the resident being ready for discharge. The facility staff admitted to telling the hospital ER they would not accept RES #6 back, citing concerns about behavioral issues and potential danger to others. The resident remained in the ER for three days without medications from the facility. Interviews with the resident, family representatives, hospital social worker, and facility staff confirmed the refusal and lack of proper discharge planning. The facility did not document efforts to find alternative care for RES #6.

The facility failed to follow regulations and its written policy by not allowing RES #6 to return after being sent to the emergency room for acute care on 11/11/2023. This placed residents at risk for not receiving necessary care. Documentation and interviews revealed RES #6 exhibited behavioral issues, was sent multiple times to the hospital ER, and was ultimately not accepted back by the facility despite being ready for return. The facility did not send RES #6's medications to the hospital, and the resident stayed in the ER for three days before discharge to a legal authorized representative. The facility's administration and nursing staff provided conflicting statements about the refusal to accept RES #6 back, and no documentation supported attempts to find alternate accommodations.

The facility failed to maintain cleanliness in one resident room, which had spattered and smeared orange and brown substances on the wall and a strong foul odor. This condition placed residents at risk of decreased feelings of self-worth and diminished quality of life. The facility's Environmental Services policy requires a quality control program maintained by housekeeping and laundry departments.

The facility failed to provide privacy curtains in shared resident rooms, maintain a safe and sanitary environment including clean air vents and well-maintained walls and ceilings, and ensure firmly secured handrails in resident bathrooms. These deficiencies posed risks to resident privacy, dignity, health, and safety.