Greentree Manor Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Greentree Manor Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Mar 22, 2023

  Based on observations, review of facility documentation, review of sampling quality reports, and interviews, the facility failed to conduct an assessment prior to the implementation of carpet and floor removal including but not limited to asbestos testing. The facility initiated the scope of work by allowing vendors to rip up carpeting and underlying flooring (which was later determined to contain asbestos) on 2 nursing units during the hours of 8:00 AM and 5:00 PM, resulting in gaps in flooring and uneven surfaces, floors laden with loose tile fragments, and an inability to effectively clean these surfaces. Residents were observed in the hallways seated in wheelchairs and ambulating through the debris. […]

• Actual harm, isolatedF658May 6, 2025

  Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 sampled residents (Resident # 23) reviewed for accidents, the facility failed to utilize a gait belt for transfers, failed to conduct a Registered Nurse (RN) assessment following a fall and prior to further movement, once transferred failed to conduct a thorough assessment, and failed to contact the physician representing a failure to maintain professional standards of practice. The findings include: Resident #23's diagnoses included dementia, malignant neoplasm of the anal canal, morbid obesity, and was actively receiving chemotherapy. […]

• Actual harm, isolatedF689May 6, 2025

  Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 sampled residents (Resident # 23) reviewed for accidents, the facility failed to ensure a resident was transferred appropriately, failed to end the transfer and call for the Registered Nurse to assess the resident when he/she complained of pain, failed to ensure a Registered Nurse conducted a thorough assessment that included a range of motion prior to transferring the resident off the floor, and failed to notify the physician of the fall which resulted in a major injury. The findings include: Resident #23's diagnoses included dementia, malignant neoplasm of the anal canal, morbid obesity, and was actively receiving chemotherapy. […]

• Actual harm, isolatedF600May 25, 2023

  Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #55) reviewed for an allegation of mistreatment, the facility failed to ensure the resident was free from neglect. The findings include: Resident #55's diagnosis included anxiety, morbid obesity, osteoarthritis, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #55 was cognitively intact (no cognitive deficit), and required the extensive assistance of 2 staff with bed mobility, the assistance of 1 staff with toilet use, and was occasionally incontinent of urine and frequently incontinent of bowel. […]

• No harm, potential for more than minimal, patternF602Dec 2, 2025

  Based on clinical record reviews, facility documentation, facility policies and interviews for five (5) of eight (8) sampled residents (Residents #1, #2, #3, #4, and #5) who were reviewed for allegations of misappropriation of personal property, the facility failed to ensure the residents' medications were not removed from the facility by staff. The findings include:Resident #1's diagnoses included osteomyelitis of the right ankle, diabetes mellitus with polyneuropathy, and left foot amputation. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily living. […]