Pennsylvania Department of Health
GREENE HEALTH & REHAB CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GREENE HEALTH & REHAB CENTER
Inspection Results For:

There are  126 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
GREENE HEALTH & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a complaint survey completed on May 28, 2025, it was determined that Greene Health and Rehab Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:


Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of eight residents reviewed (Resident 6).

Findings include:

The facility's abuse policy, dated September 26, 2024, indicated that the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the administrator/abuse coordinator. An investigation would begin immediately and all applicable local and state agencies would be notified in accordance with the procedures in this policy.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated December 12, 2024, revealed that the resident was understood and could usually understand others, was dependent on staff for transfers, had no behaviors, and had a diagnosis of dementia.

A nursing note for Resident 6, dated March 12, 2025, at 12:22 p.m., revealed that the Director of Nursing was notified of an allegation of neglect/abuse. A nurse aide moved the call bell from a resident's reach over the weekend and refused to get her out of bed. The facility's investigation, dated March 12, 2025, revealed that Nurse Aide 1 removed Resident 6's call bell and refused to get the resident out of bed.

A witness statement by Licensed Practical Nurse (LPN) 2, signed and undated, regarding the incident of March 9, 2025, revealed that Nurse Aide 1 reported to her that Resident 6 was not getting out of bed because she had "played" in her bowel movement after Nurse Aide 1 washed her. Resident 6 rang the call light multiple times asking to get out of bed. During the dinner tray pass, Resident 6 was hitting her remote off the table and LPN 2 heard Nurse Aide 1 say "stop hitting your remote off the table or I will move your table too." Resident 6's call light was noted to be draped over the night stand. Resident 6 said, "I don't have my call bell, they moved it."

A witness statement by Nurse Aide 3, dated March 11, 2025, revealed that she was not aware that Resident 6's call bell was out of reach and denied involvement with it being moved.

A witness statement by Nurse Aide 1, dated March 13, 2025, revealed that she had worked the past Saturday and Sunday. Resident 6 started yelling that she wanted up in the middle of an emergency. She revealed that Nurse Aide 3 removed Resident 6's call bell on Saturday and when Resident 6 wanted to get out of bed on Sunday Nurse Aide 3 said the resident was not getting out of bed.

A witness statement from Registered Nurse 4, dated March 14, 2025, revealed that Nurse Aides 1 and 3 informed her that they moved the call bell away from Resident 6 so she could not reach it and bother them because they were too busy to deal with her that day.

Interview with the Nursing Home Administrator on May 18, 2025, at 4:30 p.m. confirmed that Nurse Aides 1 and 3 were both assigned to Resident 6's hall and accused each other of removing the call bell. Resident 6's call bell was removed and she was not allowed out of bed. The investigation determined that Nurse Aide 1 removed the call bell, but Nurse Aide 3 was aware and Registered Nurse 4 was aware of the incident but did not report it timely per the abuse policy.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(b)(1)(e)(1) Management.

28 Pa. Code 201.29(j) Resident Rights.

28 Pa. Code 211.12 (d)(5) Nursing Services.



 Plan of Correction - To be completed: 06/27/2025

The submission of this plan of correction does not constitute admission or agreement on the part of the provider with the deficiencies or conclusions contained in the Statement of Deficiencies. This plan of correction is prepared and executed solely to respond to the allegation of non-compliance cited during the survey ended on May 28, 2025.

1. Actions taken for the situation identified:
The facility cannot retroactively address these situations. Nurse Aides 1 and 3 were suspended pending investigation, and their employment at the facility was terminated. Registered Nurse 4 was re-educated on the facility's policy for reporting abuse and neglect allegations. Resident 6 was interviewed and did not recall the situation. A head-to-toe assessment was completed, an event report was submitted to the Department of Health, and Adult Protective Services was notified.

2. How the facility will act to protect residents in similar situations:
The Director of Nursing/designee interviewed capable residents to ensure there were no concerns with care and services and licensed nurses completed skin assessments on incapable residents to ensure no concerns related to lack of care.

3. System changes and measures to be taken:
The Nursing Home Administrator/designee re-educated current staff on the abuse policy and procedure, including timely reporting of abuse and neglect allegations.

4. Monitoring mechanisms to assure compliance:
To monitor and maintain compliance, the Director of Nursing/Designee will interview 5 capable residents weekly for 4 weeks, then monthly for 2 months regarding abuse and neglect concerns. The Director of Nursing/designee will also complete head-to-toe assessments of 5 incapable residents weekly for 4 weeks, then monthly for 2 months, to identify signs of abuse or neglect. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings for additional recommendations as necessary, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure facility continues to meet quality standards.

5. Date Corrective Action will be completed:
Substantial compliance is expected by June 27, 2025.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of eight residents reviewed (Resident 2).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated April 11, 2025, revealed that the resident was cognitively intact, needed assistance from staff for daily care needs, and had diagnoses that included paraplegia (no feeling below the abdomen), wound infection, and a Stage 4 pressure ulcer (wound that exposes bone, tendon or muscle).

Physician's orders for Resident 2, dated April 5, 2025, included an order for the resident to receive 4.5 grams of Piperacillin-tazobactam (antibiotic) intravenously (IV-administered through the vein) every eight hours.

A review of Resident 2's Medication Administration Record for April 2025 revealed no documented evidence that the resident received the Piperacillin-tazobactam per physician's orders on April 6, 2025, at 12:00 a.m., 8:00 a.m., and 4:00 p.m.

A nursing note for Resident 2, dated April 6, 2025, at 2:28 a.m., revealed that the resident requested bed rails and an air mattress for repositioning and pressure ulcers.

A wound consult for Resident 2, dated April 7, 2025, at 10:45 a.m. revealed that the Certified Registered Nurse Practitioner (CRNP - an advanced practice nurse who can diagnose and treat medical conditions, prescribe medications, and provide comprehensive patient care) recommended an air mattress for the resident's pressure ulcers; however, a review of Resident 2's clinical record revealed no documented evidence that the resident received an air mattress per the wound consultant's recommendation and resident's request.

Interview with the Director of Nursing on May 28, 2025, at 2:36 p.m. confirmed that Resident 2 did not receive IV Piperacillin per physician's orders. She also confirmed that there was no documented evidence that the resident received an air mattress per the wound consultant CRNP's recommendation and resident's request.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.



 Plan of Correction - To be completed: 06/27/2025

1. Actions taken for the situation identified:
The facility cannot retroactively address these situations, and Resident 2 is no longer a resident at the facility.

2. How the facility will act to protect residents in similar situations:
Facility baseline was completed to ensure that medications are being administered as order by the physician. A review of current orders for air mattresses was completed to ensure mattresses are in place per physician recommendation and order.

3. System changes and measures to be taken:
The Director of Nursing/designee will monitor the compliance of medication administration and completion of physician orders as part of clinical morning meetings. The Director of Nursing/designee has educated licensed nurses and agency nurses on medication administration and the policy on physician orders, including their responsibility to follow the orders established by the physician.

4. Monitoring mechanisms to assure compliance:
The Director of Nursing/designee will perform medication administration audits to observe medications are being administered as ordered by the physician. This audit will be completed on 10% of residents each week for 4 weeks, then monthly for 2 months. The Director of Nursing/designee will also audit the wound consultant orders weekly for 4 weeks, then monthly for 2 months to ensure they have been implemented. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings for additional recommendations as necessary, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure facility continues to meet quality standards.

5. Date Corrective Action will be completed:
Substantial compliance is expected by June 27, 2025.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port