Inspection Report Summary
The most recent inspection on August 1, 2025, found deficiencies related to assessments, care plans, medication storage, infection control, and environmental safety. Earlier inspections were not provided for comparison, so broader patterns cannot be determined from the available information. The main issues involved documentation accuracy, expired medications, infection prevention practices, and maintenance concerns such as water damage and malfunctioning call systems. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports, and no complaint investigations were noted. Without prior inspection data, it is unclear whether these findings represent a new or ongoing trend.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
77% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Aug 1, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with federal regulations related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including accurate resident assessments, care plan development and implementation, infection control practices, medication labeling and storage, resident safety and supervision, call light functionality, and environmental safety due to water damage and mold.
Deficiencies (9)
Failed to ensure Minimum Data Set (MDS) assessments accurately reflected resident status, specifically falls for Resident 8.
Failed to develop and implement a comprehensive person-centered care plan for Resident 8, including timely interventions for fall prevention.
Failed to ensure residents (R1 and R6) were afforded the opportunity to participate in the development of their care plans.
Failed to provide adequate supervision and assistive devices to prevent accidents for Resident 8, including failure to implement fall risk interventions such as non-skid strips and proper monitoring.
Failed to ensure drugs and biologicals were labeled properly and expired medications were removed from storage areas.
Failed to ensure residents received food that accommodated allergies, intolerances, and preferences for four residents reviewed.
Failed to maintain an effective infection prevention and control program, including failure to implement Enhanced Barrier Precautions for residents with clinical indications.
Failed to ensure a working call system was available in each resident's bathroom and bathing area, resulting in malfunctioning call lights and inadequate alternative call devices for residents 98 and 117.
Failed to ensure the nursing home environment was safe, clean, and comfortable, with water damage and mold present on the 300 Hall ceiling affecting residents 99 and 106.
Report Facts
Fall incidents: 11
Expired medications: 10
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide 11 | CNA | Mentioned in relation to fall prevention care plan and supervision of Resident 8. |
| Registered Nurse 7 | RN | Mentioned in relation to fall prevention care plan and supervision of Resident 8. |
| Director of Nursing | DON | Provided statements regarding care plan expectations, fall prevention, infection control, and medication management. |
| Administrator | Provided statements regarding facility policies, resident safety, medication management, and call light system. | |
| Certified Nurse Aide 2 | CNA | Observed providing care without gown for resident on Enhanced Barrier Precautions. |
| Assistant Director of Nursing | ADON | Served as Infection Preventionist and provided statements on infection control practices. |
| Maintenance Director | Provided information on call light system issues and water damage repairs. | |
| Maintenance Assistant | Provided information on call light system malfunction due to condensation. | |
| Social Services Director | SSD | Provided information on care plan meeting invitations and documentation. |
| MDS Nurse 2 | MDS Nurse | Reviewed and corrected inaccurate MDS assessments for Resident 8. |
Inspection Report
Abbreviated Survey
Census: 123
Deficiencies: 7
Date: Aug 1, 2025
Visit Reason
A Recertification and Abbreviated Survey was conducted from 07/29/2025 to 08/01/2025 to investigate compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Regulatory deficiencies were identified related to accuracy of assessments, comprehensive care plans, medication storage, infection control, and environmental safety.
Deficiencies (7)
Accuracy of Assessments - Registered nurse must sign and certify assessments; penalty for falsification; discrepancies found in MDS assessments.
Develop and Implement Comprehensive Care Plan - Care plans lacked documentation of resident and family participation; no evidence of care plan meetings for some residents.
Storage of Drugs and Biologicals - Expired medications found in medication room refrigerator and hall medication refrigerator.
Food that accommodates resident allergies, intolerances, and preferences - Facility failed to ensure residents received food accommodating allergies and preferences.
Infection Prevention and Control - Facility failed to maintain infection prevention program; staff failed to use appropriate PPE and follow hygiene procedures.
Resident Call System - Call lights malfunctioning; some residents unable to use call system properly.
Environmental Safety - Water damage and ceiling issues in resident rooms; mold and discolored areas noted.
Report Facts
Survey Census: 123
Sample Size: 28
Supplemental Residents: 6
Deficiencies cited: 7
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jul 5, 2022
Visit Reason
The inspection was conducted based on complaint investigations related to resident safety, care plan implementation, infection control, and food safety at Greenwood Rehabilitation and Healthcare Center.
Complaint Details
The complaint investigation substantiated allegations of resident-to-resident physical abuse and multiple falls with injuries. The facility failed to implement adequate care plans and supervision to prevent these incidents. Infection control lapses and food safety concerns were also identified.
Findings
The facility was found to have failed in protecting residents from physical abuse, implementing comprehensive care plans with measurable objectives, ensuring adequate supervision and assistive devices to prevent falls, maintaining proper catheter care, following infection prevention and control protocols, and storing food safely. Multiple incidents of resident-to-resident abuse and falls with injuries were documented, along with lapses in infection control practices and food storage.
Deficiencies (7)
Failed to protect one resident from physical abuse by other residents.
Failed to implement a comprehensive person-centered care plan with measurable objectives for two residents, including fall prevention and safety interventions.
Failed to provide adequate supervision and assistive devices to prevent falls for one resident with a history of multiple falls.
Failed to ensure appropriate care for a resident with an indwelling urinary catheter, including proper catheter drainage bag positioning.
Failed to provide and implement an infection prevention and control program, including proper cleaning of shared equipment, PPE use, hand hygiene, and safe linen handling.
Failed to store food in accordance with professional standards; specifically, food items were not dated when removed from original packaging and placed in the freezer.
Failed to maintain a safe, functional, sanitary, and comfortable environment by leaving hazardous cleaning wipes unattended within residents' reach.
Report Facts
Residents sampled: 47
Falls sustained: 11
Fifteen minute checks order: 15
Pages in report: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #6 | LPN | Documented nursing progress notes related to Resident #75's falls and care |
| Housekeeper #1 | Housekeeper | Witnessed resident altercation and reported incident |
| Registered Nurse #2 | RN | Provided nursing progress notes and interviews regarding Resident #75's wandering and falls |
| Certified Medication Aide #1 | CMA | Interviewed regarding resident redirection and fall incidents |
| Director of Nursing | DON | Conducted investigations and interviews related to abuse and falls |
| Administrator | Facility Administrator | Provided statements on staff awareness and facility challenges |
| Certified Nursing Assistant #3 | CNA | Interviewed about care plan adherence and resident supervision |
| Director of Rehabilitation | Therapy Director | Provided therapy evaluations and recommendations for Resident #75 |
| Licensed Practical Nurse #8 | LPN | Interviewed about care plan interventions for Resident #75 |
| Certified Nursing Assistant #2 | CNA | Observed and interviewed regarding infection control practices |
| Licensed Practical Nurse #5 | LPN | Interviewed about cleaning shared equipment and infection control |
| Registered Nurse #7 | RN | Observed and interviewed regarding hand hygiene and medication administration |
| Certified Nursing Assistant #1 | CNA | Observed and interviewed regarding PPE use and linen handling |
| Unit Coordinator | UC | Interviewed about infection control policies and linen handling |
| Quality Improvement/Infection Preventionist Nurse | QI/IP Nurse | Interviewed about infection control program and staff training |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 11, 2019
Visit Reason
The inspection was conducted based on complaints regarding improper medication storage and infection prevention and control practices at Greenwood Rehabilitation and Healthcare Center.
Complaint Details
The complaint investigation revealed substantiated issues with medication storage and infection control practices, including improper medication handling by RN #1 and improper glove use and hand hygiene by LPN #1 and CNAs during resident care.
Findings
The facility failed to ensure medications were stored securely and properly supervised during administration, and failed to maintain an effective infection prevention and control program, including improper glove use and hand hygiene by staff during resident care.
Deficiencies (2)
Failure to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys; medication left unattended on medication cart.
Failure to provide and implement an infection prevention and control program, including use of contaminated gloves for medication administration and failure of staff to wash hands and change gloves during resident care.
Report Facts
Residents sampled: 28
Residents affected: 2
Date of medication pass observation: Oct 9, 2019
Date of infection control observation: Oct 8, 2019
Date of peri care observation: Oct 9, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Left medication unattended on medication cart during medication pass |
| LPN #1 | Licensed Practical Nurse | Used contaminated glove to administer G-Tube medication |
| Director of Nursing | Director of Nursing | Provided expectations regarding medication storage and infection control practices |
| CNA #7 | Certified Nurse Aide | Failed to wash hands and change gloves during peri care |
| CNA #8 | Certified Nurse Aide | Failed to wash hands and change gloves during peri care |
| Charge Nurse/LPN #2 | Charge Nurse / Licensed Practical Nurse | Unable to answer questions about proper peri care technique |
| Unit Manager/LPN #3 | Unit Manager / Licensed Practical Nurse | Stated CNAs should have changed gloves and washed hands prior to providing clean brief and bed clothing |
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