Greene Acres Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Greene Acres Rehabilitation and Nursing, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF909Oct 27, 2022

  Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to inspect a bed frame and mattress for one of twenty residents in the survey sample (Resident #43) and failed to implement a facility-wide program for inspecting bed frames, mattresses and bed rails for possible entrapment risks and bed/mattress compatibility for sixty-nine of sixty-nine beds currently in use by residents. The findings include: Resident #43 was admitted to the facility with diagnoses that included congestive heart failure, anxiety, dementia with behaviors, atrial fibrillation, mood disorder, deep tissue damage of right heel and depression. […]

• No harm, potential for more than minimal, patternF657Jun 17, 2026

  Based on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for 4 of 19 residents, Resident's #1, #2, #7, and #22.The findings included: 1. For Resident #1 (R1), the facility failed to update the Comprehensive Care Plan to reflect changes regarding active infection and administration of supplemental oxygen. Diagnoses for R1 include dementia, chronic obstructive pulmonary disease (COPD), cerebral ischemia, and interstitial pulmonary disease. On the most recent Minimum Data Set (MDS) assessment, a quarterly assessment with an assessment reference date (ARD) of 3/28/2026, R1 scored a four out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF760Jun 17, 2026

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure 3 of 19 residents, were free of significant medication errors, resident #4, #67, and #75. The findings included:1.For Resident #4 the facility staff failed to administer the medication levothyroxine on multiple occasions. Resident #4's clinical record listed diagnoses which included but not limited to hypothyroidism. Resident #4's most recent minimum data set with an assessment reference date of 06/02/26 assigned the resident a brief interview for mental status score of 5 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #4's comprehensive care plan was reviewed and contained a plan for . […]

• No harm, potential for more than minimal, patternF812Jun 17, 2026

  Based on observation, staff interview and facility document review, the facility staff failed to dispose of expired food in 2 of 2 facility pantries. The findings included:A facility policy entitled, Use and Storage of Food Brought in by Family or Visitors with a reviewed/revised date of 12/1/22 read in part, It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. Under the heading Policy Explanation and Compliance Guidelines the document read in part, 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. a. […]

• No harm, potential for more than minimal, patternF883Jun 17, 2026

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide education for the influenza vaccine for 5 of 5 residents (Residents # 7, #12, #57, #70 and #81), failed to provide education for the pneumonia vaccine for 2 of 5 residents (Residents #12 and #7), and failed to offer vaccines for 1 of 5 residents (Resident #7) sampled residents. The findings included:Five residents were chosen from the initial pool for review of vaccinations. Of these 5 residents, there was no evidence that Resident #7 had been offered either the flu or pneumonia vaccine or education provided related to these vaccines. Resident #12 had refused both the flu and pneumonia vaccine, and there was no evidence that education was provided for these vaccines. […]