Greenery Center for Rehab and Nursing

Inspectors wroteBased on facility review of policy, manufacturer's instructions, clinical records and staff interviews, the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for 12 of 21 residents (R2, R4, R16, R33, R37, R46, R47, R56, R70, R80, R97, and R116).

Inspectors wroteBased on review of employee files, and staff interviews, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian for 25 of 25 days. (March 16, 2026, through April 10,2026)

Inspectors wroteBased on observations, resident interviews, review of facility documents, and staff interviews, it was determined that the facility failed to provide sufficient dietary staff to perform essential kitchen duties.

Inspectors wroteBased on a review of facility policy, facility documents, resident interviews, staff interviews and observations, it was determined the facility failed to provide the residents with food and drink that is at a safe and appetizing temperatures for five of 21 residents interviewed (R59, R115, R98, R76 and R9), 14 of 14 residents in a confidential group meeting, two of three resident council minutes reviewed (1/5/26 and 3/2/26), and observations of a test tray (4/9/26).

Inspectors wroteBased on review of the facility documents and resident and staff interviews, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to ensure that the delivery of care and services was effectively provided to residents.

Inspectors wroteBased on review of facility policy, documentation, and staff interviews it was determined that the facility failed to implement control measures for Legionella within the facility for three of twelve months (February, March, and April 2026).

Inspectors wroteBased on review of facility documents, resident council minutes, and resident interviews, it was determined that the facility failed to provide services in an atmosphere of dignity and respect for six of twenty residents (Residents R9, R21, R26, R63, R64, and R86) and seven of fourteen confidential group residents (Residents R100, R200, R400, R600, R700, R900, and R901). Findings Include: Review of the facility-provided document, Your Rights and Protections as a Nursing Home Resident indicated:At a minimum, Federal law specifies that nursing homes must protect and promote the following rights of each resident. You have the right to: Be Treated with Respect: You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose. You have the right to decide when you go to bed, rise in the morning, and eat your meals. [...]

Inspectors wroteBased on review of facility documents, resident council documents, resident council group interview, resident interview, and staff interview it was determined that the facility failed to respond to concerns from resident council and failed to respond to concerns in a timely manner for six out of six months (10/7/25, 11/4/25, 12/2/25, 1/6/26, 2/2/26, 2/4/26, and 3/3/26).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide information regarding how to file a grievance and information on the grievance official on three of three nursing units (South, North, and [NAME] nursing units). During an observation of the North nursing unit on 4/9/26, at approximately 10:00 a.m. a grievance box was noted, with forms. Information on the grievance official's name and contact information, the right to file grievances orally, in writing, or anonymously, and the expected time frame for completion of the grievance review was not provided. During an observation of the South nursing unit on 4/9/26, at approximately 10:05 a.m. a grievance box was noted, with forms. [...]

Inspectors wroteBased on facility policy and clinical record review and staff interview, it was determined that the facility failed to complete a restorative nursing program for four of six residents reviewed for ADLs (activities of daily living) concerns (Residents R24, R31, R78, and R93).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to properly monitor weight as ordered for four of six residents (Residents R15, R18, R29, and R33).

Inspectors wroteBased on review of facility documents, resident observations and interviews, Resident Council minutes, confidential resident group interview, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of eleven of twenty residents (Resident R21, R26, R56, R63, R64, R86, R117, R118, R119, R120, R121), seven of fourteen confidential group residents (Residents R100, R200, R400, R500, R600, R700, and R900), and for five of six Resident Council monthly meetings (October 2025, November2025, December 2025, and February 2026 and March 2026). Findings Include: [...]

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to complete annual performance evaluations for five of five nurse aides (Employees E2, E3, E4, E5, and E6).

Inspectors wroteBased on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to ensure provider notification of resident changes in condition. This failure resulted in immediate jeopardy for 12 of 21 residents (R2, R4, R16, R33, R37, R46, R47, R56, R70, R80, R97, and R116).

Inspectors wroteBased on a review of select facility policies and procedures, current Centers for Disease Control (CDC) guidelines, clinical record review, and staff interview, it was determined that the facility failed to document each resident was offered a Covid 19 immunization and the resident or resident's representative was provided education regarding the benefits and potential side effects of immunizations, for four of five residents reviewed for immunizations (Residents R20, R24, R31, and R98).

Inspectors wroteBased on review of facility documents, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for five of five nurse aides (Employees E2, E3, E4, E5, and E6).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters waste, salt and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of five residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policies, observations and staff interview, it was determined that the facility failed to make certain that out of date medications were discarded in one of three medication rooms (North Unit medication room) and failed to properly secure a treatment cart on one of two nursing units (South Unit).

Inspectors wroteBased on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of three quarterly meetings (Quarter four of 2025). Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) policy dated 1/5/26, indicated the QAPI program is an ongoing comprehensive program that addresses all the systems of care and shall evaluate, monitor, and investigate quality of care in the facility. Meeting, at a minimum, at least quarterly; monthly or more often if needed. Review of Quality assurance and Performance Improvement sign in sheets and attendance records for Quarter Four of 2025, failed to reveal a meeting was held as required. During an interview on 4/10/26, at 10:40 a.m. [...]

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to accurately complete the Facility Assessment.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for three of six residents reviewed for hospitalization (Resident R8, R15, and R30).

Inspectors wroteBased on observation and staff interviews it was determined that the facility failed to maintain the confidentiality of residents' personal identifiable information on two of three nursing units (North and South Nursing Units) and failed to provide privacy during provision of care on one of three nursing units (North Nursing Unit).

Inspectors wroteBased on a review of facility policy, observations and staff interview it was determined that the facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness and cross contamination. Findings Include:Review of the facility policy Dietary Food Handling dated 1/5/26, indicated that thermometers must be placed in hot and cold storage areas in accordance with public health standards. Foods must be stored off of the floor. Clean uniforms must be worn daily, and hairnets or caps must be worn in all food service areas. Review of the Pennsylvania Food Code S46.152 indicated employee shall wear hair restraints including beard restraints. All food items will be stored at least six inches off the floor. Review of S483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. [...]

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on three of three nursing units (North, South and [NAME] nursing units). Based on observations and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (North and South nursing units).

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to maintain an environment free of potential accident hazards and obstacles for safe mobility and use of mobility assistance devices on two of three nursing units (North and South Nursing Units).

Inspectors wroteBased on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident on three of three nursing units (North, South and [NAME] Nursing units). Findings Include:Review of facility policy, Medication Ordering and Receiving from Pharmacy, last reviewed 1/5/26, indicated that the facility maintains a supply of commonly used over the counter medications considered as floor stock to be administered upon receipt of an order from an authorized prescriber. Review of a complaint and a grievance dated January 2026, identified that common over the counter medications are not available. [...]

Inspectors wroteBased on review of facility documents, resident council group interviews, and staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents for three of three Nursing Units (North, South and [NAME] Nursing Units).

Inspectors wroteBased on staff interviews and observations, it was determined the facility failed to maintain a fully functioning resident call bell system that allows residents to call for staff assistance through a communication system on one of three nursing units (West nursing unit).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen).

Inspectors wroteBased on review of facility documents, observations, and resident and staff interviews it was determined that the facility failed to provide necessary services to maintain grooming and personal hygiene for seven of twelve residents (Residents R500, R503, R504, R505, R507, R16 and R86).

Inspectors wroteBased on staff interviews and review of facility provided documentation, it was determined the facility failed to provide a qualified professional to direct the activities program as required from (4/9/24 through 5/9/25).

Inspectors wroteBased on review of facility policy, clinical records, observations and and staff interviews, it was determined that the facility failed to provide ostomy (surgically-made opening that allows waste to pass out of the body) care and services consistent with professional standards of practice for three of four residents (Resident R73, R144, and R300).

Inspectors wroteBased on observations and interview, the facility failed to ensure medical supplies were properly disposed of and not reused for one of four residents with an ostomy (hole made in abdominal wall to allow urine/feces to pass through); failed to ensure the consistent implementation of infection control procedures during medication administration for one of three observations; and failed to store medications in a safe and sanitary manner for two of three medication carts reviewed (North cart #2, and North cart #1)

Inspectors wroteBased on review of facility policy, facility records, resident, and staff interviews, it was determined that the facility failed to make certain call bells were answered timely for five of eight residents as required (Resident R500, R503, R505, R506, and R507).

Inspectors wroteBased on review of facility policy, facility documentation and clinical record review, and staff interviews it was determined that the facility failed to investigate potential neglect for one of 11 residents (Resident R300).

Inspectors wroteBased on review of facility policy, resident clinical record, personnel record, and staff interview it was determined that the facility failed fully investigate an allegation of neglect for one out of three resident records (Resident R300).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop a baseline care plan for two of four residents (Resident R144 and R193).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive care plan to meet care needs for one of five residents (Residents R142).

Inspectors wroteBased on facility policy, clinical record review and interviews with staff, it was determined that the facility failed to revise the comprehensive care plan to reflect resident's current needs for two of eight residents (Residents R17 and R18).

Inspectors wroteBased on review of facility policy, clinical record review, observations and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for one of three residents receiving enteral feedings (Resident R35).

Inspectors wroteBased on review of facility records, employee personnel records, staff interviews, and clinical records, it was determined that the facility failed to ensure nursing staff possessed the necessary competencies and skills to provide care in accordance with the resident's care plan and individual needs to promote resident safety and comfort during care for one of four residents reviewed (Residents R300).

Inspectors wroteBased on a review of facility policies, documents, clinical documentation, observations and staff interview it was determined that the facility failed to assess a resident receiving enteral feedings in a timely manner and failed to approve the planned menu for four of four menu cycle weeks. (Menu Cycle Week One, Two, Three and Four). Findings Include: Review of the Registered Dietician job description provided from the facility, with a policy review date of 8/9/25, indicated that the Dietician is to implement, coordinate and evaluate the medical nutrition therapy for the residents, provide resident and family education,provide nutritional assessment and consultation to assist in planning, organizing and directing the food an nutritional services of the facility. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to maintain complete and accurate documentation for one of seven residents (Residents R144).

Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Effective Communication for two of ten staff members (Employee E12 and E13).

Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for two of ten staff members (Employee E12 and E13).

Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for two of ten staff members (Employee E12 and E13).

Inspectors wroteBased on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision which resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of 15 residents who were identified as high risk for elopement (Resident R1). The facility also failed to make certain that four of 15 residents had appropriate data including pictures and identification of risk for elopement available to staff for review (Resident R2, R3, R4 and R5).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify physicians of increased capillary blood glucose (CBG) levels for three of seven residents (Resident R2, R3, and R4).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in two of three medication carts (North One and North Three medication carts).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain the confidentiality of residents' medical information for one of three medication carts (North One medication cart).

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to make certain that equipment was in safe operating condition for one of one crash carts (maintained with equipment used in cardiac emergencies).

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for two of four residents (Resident R1 and R2).

Inspectors wroteBased on a review of federal regulation and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for four of 10 months (July, August, September, and October 2024).

Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of four residents (Resident R2). This was identified as past non-compliance.

Inspectors wroteBased on a review of clinical records and staff interviews, it was determined that the facility failed to provide transportation for a scheduled appointment for one of three residents (Resident R1).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for eight of nine residents without a BIMS assessment completed (Resident R26, R28, R57, R67, R74, R75, and R91), and two of eight for inaccurate resident assessments.

Inspectors wroteBased on observations and interview, the facility failed to store medications in a safe and sanitary manner for one of three medication carts reviewed (Team #2 North).

Inspectors wroteBased on review of clinical records and staff interview it was determined that the facility failed to provide care and services according to accepted standards of clinical practice in the identification of a resident's diagnosis of schizoaffective disorder for one resident of two residents (Resident R34).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of four residents reviewed (Resident R23).

Inspectors wroteBased on review of facility documents and staff interview it was determined that the facility failed to fully complete the Facility Assessment.

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify physicians of increased capillary blood glucose (CBG) levels for three of seven residents (Resident R1, R4, and R18).

Inspectors wroteBased on resident observations and interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 13 of 15 residents (Resident R1, R2, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17).

Inspectors wroteBased on review of clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for three of four residents (Residents R1, R2, and R3).

Inspectors wroteBased on review of facility policies, observations and staff interview, it determined the facility failed to maintain sanitary conditions to prevent the potential for cross contamination during lunch time tray line.