Greenhaven Health And Rehabilitation Center
Greenhaven Health and Rehabilitation Center in Greensboro, NC — inspection on September 4, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
employee ensured the service hall door was secured and then proceeded to leave the facility with his transportation, believing the gentleman who came out behind him was walking around the front to meet his own ride.At approximately 8:30 pm, Medication Aide #1 attempted to administer Resident #1's, evening medications but was unable to locate him.
Medication Aide #1 notified Nurse #1 that Resident #1 could not be located. A facility-wide search was immediately initiated, and a code orange (code used to notify all staff of a missing resident) was announced by Nurse #1.
The Director of Nursing (DON) and Administrator were notified that resident #1 could not be located.
Staff continued to search for resident #1 inside the facility and in the surrounding areas in their vehicles. At approximately 9:49 pm, the Administrator notified law enforcement that Resident #1 could not be located. At approximately 10:00 pm, local law enforcement arrived onsite to begin searching for Resident #1. At approximately 10:36 pm, the Administrator notified the Resident Representative (resident's daughter) that resident #1 could not be located. At approximately 10:45 pm, the police department notified the Administrator that the resident was located 0.9 miles away from the facility.
The Director of Nursing and a Nursing Assistant #1 went to the location of the resident.
The resident was uncooperative with EMS, so the family was contacted by the DON and made the decision for the resident to be brought back to the facility. Resident #1 was brought back to the facility via the staff's private vehicle, where the family was onsite at arrival.
The Director of Nursing discussed with the resident's family the need for the resident to be sent to the emergency room (ER).
The family agreed, and EMS was notified.
An assessment was completed by the assigned hall nurse and revealed a laceration approximately one inch to the right cheek and a 3/4 inch abrasion above both knees.
Treatment was provided to the areas along with resident care. EMS arrived to evaluate the resident and found the resident to be stable.
The family decided to discharge the resident Against Medical Advice (AMA) and take the resident to the ER via their private vehicle. At approximately 11:32 pm, the physician services were notified by the DON of the incident and the family's decision to discharge the resident AMA. At approximately 12:00 pm, the resident left AMA with family.On 8/6/25, the Administrator completed a root cause analysis for Resident #1's unsupervised exit.
The investigation identified the root cause to be that Resident #1 walked out behind a dietary aide, and the dietary aide did not intervene to prevent an unsupervised exit, thinking he was a visitor.
Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On 8/5/25, t[TRUNCATE
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