Greentree Health and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, had a national certification for food service management and safety from a national certifying body, or had an associate's or higher level degree in food service management or hospitality. This practice had the potential to affect all 32 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility did not complete a Pre-admission Screening and Resident Review (PASRR) assessment for 1 resident (R) (R37) of 14 sampled residents. R37 was admitted to the facility on [DATE]. A PASRR Level I Screen was not completed at the time of admission.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 1 resident (R) (R37) of 1 sampled resident from a total sample of 14 residents. The facility did not ensure R37's treatment orders for a removeable boot were clearly defined or followed.

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect 2 residents (R) (R25 and R7) of 14 sampled residents. R25 was on transmission-based precautions (TBP). Staff did not wear the appropriate personal protective equipment (PPE) during cares. In addition, a TBP sign outside R25's room was not in accordance with their order. R7 was on enhanced barrier precautions (EBP). Staff did not wear the appropriate PPE during cares.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a motorized scooter battery was charged in a safe location for 1 resident (R) (R12) of 1 sampled resident. R12 had a motorized scooter. The facility chaged the battery in R12's room.

Inspectors wroteBased on staff interview, record review, and policy review, the facility failed to timely report an allegation of physical abuse for 2 residents (R) (R1 and R2) of 3 sampled residents. On 7/24/25 at approximately 6:30 AM, R1 put R1's arms around R2's neck, pulled R2 toward R1, and pinched R2's ear. Staff stated R2 appeared upset and did not want the interaction to occur. Staff did not report the abuse until another incident occurred that afternoon.

Inspectors wroteBased on staff interview, record review, and policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II referral was completed after a significant change in mental status for 1 resident (R) (R1) of 1 resident reviewed. A psychiatric evaluation on 7/23/25 indicated R1 had self-injurious behaviors and hit/pinched others. The evaluation contained recommendations to increase R1's divalproex (anticonvulsant medication) and quetiapine (antipsychotic medication). A PASARR Level II referral was not completed.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R86) of 1 sampled resident was transferred appropriately and in accordance with the facility's policy. On 4/5/25, Certified Nursing Assistant (CNA)-K transferred R86 without a gait belt. R86 fell during the transfer and sustained a head injury that required 3 staples.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 39 residents residing in the facility. Enhanced Barrier precautions (EBP) were not implemented for R187 who had an indwelling urinary catheter. Staff did not complete appropriate hand hygiene after providing care for R6. Residents were not offered hand hygiene prior to the lunch meal on 4/22/25.

Inspectors wroteBased on observation, staff and resident interview, and record, review, the facility did not maintain dignity for 3 residents (R) (R20, R11, and R6) of 23 sampled residents. R20 required feeding assistance. On 4/22/25, R20 watched other residents eat in the dining room and waited 16 minutes for assistance. In addition, staff in the dining room did not address or speak to R20. R11 and R6 required feeding assistance. On 4/22/25, staff in the dining room did not speak to R11 and R6 while feeding them.

Inspectors wroteBased on staff interview and record review, the facility did not ensure court-ordered protective placement was obtained for 1 resident (R) (R9) of 2 sampled residents. R9 was under Guardianship. The facility did not ensure court-ordered protective placement in the least restrictive environment was obtained after R9's nursing home stay exceeded 60 days.

Inspectors wroteBased on staff interview and record review, the facility did not make a prompt effort to investigate and resolve a grievance for 1 resident (R) (R5) of 1 sampled resident. R5 voiced a concern to staff and the Grievance Official that another resident repeatedly woke R5 up in the early morning hours. R5's grievance was not documented, thoroughly investigated, or resolved.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an injury of unknown origin was reported to the State Agency (SA) for 1 resident (R) (R32) of 4 sampled residents. On 4/2/25, staff discovered a hematoma on R32's left forearm. Facility staff and Hospice staff were unsure how the injury occurred. The facility did not report the injury of unknown origin to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an injury of unknown origin was thoroughly investigated for 1 resident (R) (R32) of 4 sampled residents. R32 had an injury of unknown origin that was discovered on 4/2/25. The facility did not interview other residents to rule out abuse during the investigation.

Inspectors wroteBased on staff interview and record review, the facility did not revise a care plans in accordance with current care needs for 1 resident (R) (R32) of 15 sampled residents. R32's care plan was not updated to include calling R32 by R32's preferred names. R32's care plan was also not updated when R32 incurred an injury of unknown origin and geri-sleeves were implemented to protect R32's skin.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 3 residents (R) (R7, R12, and R186) of 17 sampled residents received assistance as needed to complete activities of daily living (ADLs). R7 did not receive assistance with positioning, toileting, and breakfast. R12 did not receive weekly showers. In addition, the facility did not address R12's request for more showers. R186 did not receive a shower while at the facility.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 2 residents (R) (R23 and R189) of 3 sampled residents. On 4/22/25, staff administered R23's AM and noon medications more than an hour after the scheduled times. On 4/22/25, staff left R189's medications at the bedside for R189 to self-administer. R189 did not have a physician order to self-administer medication or a self-administration of medication assessment that indicated R189 could safely and accurately self-administer medication.

Inspectors wroteBased on staff interview and record review, the facility did not monitor for adverse reactions of a high-risk medication for 1 resident (R) (R86) of 5 sampled residents. R86 was prescribed gabapentin (an anticonvulsant medication). The facility did not monitor for adverse reactions or side effects of the high-risk medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R187) of 5 sampled residents was monitored for adverse reactions to psychotropic medication. R187 had an order for paliperidone (an antipsychotic medication). R187's medical record did not contain an Abnormal Involuntary Movement Scale (AIMS) assessment (a rating scale designed to measure involuntary movements known as tardive dyskinesia which is a disorder that can develop as a side-effect of long-term treatment with antipsychotic medication) for the use of paliperidone.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of neglect was reported to the State Agency (SA) for 1 resident (R) (R1) of 3 sampled residents. On 7/18/24, R1 had a fall with major injury. R1's care plan contained an intervention for a sensor alarm on R1's bed. The facility's fall investigation indicated a sensor alarm was not on R1's bed at the time of the fall. The facility did not report the potential neglect to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the provision of an assistive device to prevent accidents for 1 resident (R) (R1) of 3 sampled residents. R1's plan of care contained an intervention for a sensor alarm on R1's bed. On 7/18/24 at 3:45 AM, R1 sustained a fall with injury. The sensor alarm was not in place at the time of the fall.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring of high-risk medications for 1 Resident (R) (R140) of 5 sampled residents. The facility did not monitor R140 for adverse effects of anticoagulant, antidepressant, and diuretic medication.