Deficiency Records for Greentree Manor Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Greentree Manor Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2023-07-18 | 2023-08-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-18 | 2023-08-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-18 | 2023-08-29 | Y |
| Develop a communication plan. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-25 | 2023-07-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-25 | 2023-07-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-05-25 | 2023-07-06 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-05-25 | 2023-07-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-25 | 2023-07-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-25 | 2023-07-06 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-25 | 2023-07-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-25 | 2023-07-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-25 | 2023-07-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-25 | 2023-07-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-25 | 2023-07-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-25 | 2023-07-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide or obtain dental services for each resident. | Health | 2023-05-25 | 2023-07-06 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-05-25 | 2023-07-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-25 | 2023-07-06 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-25 | 2023-07-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-25 | 2023-07-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-25 | 2023-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-22 | 2023-03-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-27 | 2023-03-17 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-05 | 2022-05-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-05 | 2022-05-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-10 | 2022-05-20 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-09-21 | 2021-10-22 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-06-28 | 2021-07-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-28 | 2021-07-08 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2021-02-03 | 2021-04-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-02-03 | 2021-04-09 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-02-03 | 2021-04-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-02-03 | 2021-04-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-02-03 | 2021-04-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-02-03 | 2021-04-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-02-03 | 2021-04-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-02-03 | 2021-04-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-02-03 | 2021-04-09 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-02-03 | 2021-04-09 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-02-03 | 2021-04-09 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-02-10 | 2021-03-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-02-10 | 2021-03-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-02-10 | 2021-03-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-02-10 | 2021-03-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-02-10 | 2021-03-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-02-10 | 2021-03-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-02-10 | 2021-03-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-02-10 | 2021-03-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-10 | 2021-03-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-02-10 | 2021-03-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-10 | 2021-03-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-02-07 | 2019-03-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-02-07 | 2019-03-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-02-07 | 2019-03-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-07 | 2019-03-21 | N |
| Respond appropriately to all alleged violations. | Health | 2019-02-07 | 2019-03-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-07 | 2019-03-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-07 | 2019-03-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-07 | 2019-03-21 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-02-07 | 2019-03-21 | N |
| Dispose of garbage and refuse properly. | Health | 2019-02-07 | 2019-03-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-06 | 2019-03-20 | N |
