Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greentree Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not designate a qualified director of food and nutrition services. The DM stated they had not completed Dietary Manager certification and were still in classes, while the RD confirmed they were not a full-time employee and were only onsite every other week. The NHA stated there was no waiver for the DM and did not know one was needed.
PASARR screening was not completed for one resident on admission. The resident had mild cognitive impairment and generalized anxiety disorder, and the chart only contained a PASARR Level I Screen from a prior stay. When the surveyor requested the current PASARR, the NHA stated it had been missed; the facility later produced a PASARR showing serious mental illness and a 30-day hospital discharge exemption.
A resident with a right ankle fracture was ordered to wear a removable boot 24/7, with removal only for hygiene and ROM, but staff did not consistently remove the boot or assess the skin underneath. Interviews showed CNAs and an LPN were unsure who was responsible for the boot, the resident said it had only been removed once, and the TAR order was not clearly clarified. When the boot was removed during the survey, reddened areas, dry/flaky skin, rubbing, and other skin changes were found.
Infection control practices were not followed for two residents on precautions. One resident with suspected pneumonia had an order for droplet precautions with gown, mask, and gloves, but the posted sign did not match the order and an AD entered the room without PPE or hand hygiene. Another resident with an indwelling catheter and stage 4 pressure ulcer was on EBP, but an LPN provided catheter-related care without wearing a gown as required; the resident, LPN, and DON all confirmed the gown was not used.
Unsafe Charging of Motorized Scooter Battery: A resident with a progressive neurological condition used a motorized scooter, and surveyors observed the scooter battery charger plugged into a wall outlet in the resident’s room on multiple occasions. The facility policy required charging in a designated approved location and prohibited charging in resident rooms. The DON and ADON stated the resident preferred to charge the scooter in the room at night, and the DON acknowledged the safety concern.
Staff did not promptly report an incident where one resident physically abused another, despite observing the affected resident was upset and tearful. The incident was only reported after a second occurrence later that day, contrary to facility policy requiring immediate reporting of alleged abuse. Interviews with an LPN and the DON confirmed the delay in reporting.
A resident with severe cognitive impairment and a history of mental health disorders experienced a significant increase in self-injurious and aggressive behaviors, leading to changes in psychiatric medication. Despite these changes and multiple documented incidents, staff did not initiate a required PASRR Level II referral, and key personnel were unaware or unsure of the referral process.
A resident with hemiplegia and on anticoagulant therapy was transferred by a CNA without a gait belt, resulting in a fall and head injury requiring staples. The facility's policy required gait belt use for safe transfers, but the care plan did not specify this prior to the incident. Staff interviews confirmed the omission of the gait belt was the cause of the fall, and the care plan was only updated after the event.
The facility did not maintain an effective infection control program, as staff failed to implement Enhanced Barrier Precautions for a resident with an indwelling catheter, did not perform proper hand hygiene after handling soiled items, and did not offer hand hygiene to residents before meals. These actions were inconsistent with facility policies and infection prevention standards.
A resident with severe cognitive impairment and on palliative care developed a large hematoma of unknown origin on the left forearm. Facility and Hospice staff could not determine how the injury occurred, and although an internal investigation was completed, the incident was not reported to the State Agency as required by facility policy. The DON confirmed the omission during the survey.
A resident with severe cognitive impairment and multiple health conditions was found with unexplained bruising and a large hematoma. The facility conducted an internal investigation by interviewing staff and the resident's POAHC, but failed to interview other residents as required by its Abuse Prevention policy. The DON confirmed this omission.
A resident with severe cognitive impairment and behavioral challenges did not have their care plan updated to reflect approved preferred names for staff to use or the implementation of geri-sleeves for skin protection after an injury. Despite staff and POAHC discussions and new interventions, the care plan remained outdated, as confirmed by facility leadership.
Three residents did not receive necessary assistance with ADLs, including repositioning, toileting, meal setup, and showers. One resident was left in an uncomfortable position and not checked for incontinence or assisted with eating for several hours. Another resident did not receive weekly showers or have their request for more frequent showers addressed, and a third resident was not offered a shower since admission, with no documentation of refusals or skin checks. Facility policies requiring regular ADL support and documentation were not followed.
Three residents requiring feeding assistance were not provided with timely service or appropriate communication during meals. One resident waited 16 minutes to be served and was left mid-meal without explanation, while two others were fed without any staff interaction or conversation. Staff interviews confirmed that such practices were common and not all staff engaged with residents during mealtimes, contrary to facility policy.
A resident with schizophrenia, epilepsy, and major depressive disorder, who was under guardianship and unable to complete a mental status interview, remained in the facility beyond 60 days without a court-ordered protective placement. The facility had only a petition for protective placement on file and did not obtain the final court order, with both the social worker and NHA unaware of the missing documentation.
A resident with multiple sclerosis and anxiety disorder repeatedly complained to staff and the Grievance Official about being disturbed early in the morning by another resident's yelling. The complaint was not documented, investigated, or resolved according to facility policy, and staff interviews revealed confusion about the grievance process and inconsistent follow-through.
Staff did not administer medications within the required timeframe for one resident and left medications at the bedside for another resident to self-administer without a physician order or assessment. These actions were not in accordance with facility policy or physician instructions, as confirmed by staff interviews and record review.
A resident with a history of stroke and on long-term anticoagulants was prescribed gabapentin for neuropathic pain and restless leg syndrome. The facility did not document or implement monitoring for adverse reactions or side effects of this high-risk medication, a deficiency confirmed by the DON during record review.
A resident with severe cognitive impairment fell and sustained a major injury in a facility. The care plan required a sensor alarm on the bed, but it was not in place at the time of the fall. Staff interviews revealed inconsistent use of the alarm, yet the facility did not report the potential neglect to the State Agency.
A resident with severe cognitive impairment and a history of falls did not have a sensor alarm in place as per their care plan, leading to a fall with injury. Staff interviews revealed inconsistencies in the awareness and implementation of the alarm, with the Regional Administrator confirming its absence during the incident.
Unqualified Food and Nutrition Services Director
Penalty
Summary
The facility did not designate a person to serve as the director of food and nutrition services who met the required qualifications of being a certified dietary manager, a certified food service manager, having a national certification for food service management and safety from a national certifying body, or having an associate's or higher degree in food service management or hospitality. During an initial kitchen tour, the Dietary Manager stated they had not received their Dietary Manager certification and were still enrolled in classes without having completed them. The Dietary Manager also stated the facility's Registered Dietician was not a full-time employee and was usually at the facility once every other week. When the surveyor requested the required certification or an applicable waiver, the Nursing Home Administrator stated the facility did not have a waiver for the Dietary Manager and did not know one was needed. The Registered Dietician later confirmed they were not a full-time employee, were in the facility in person every other week, and attended weekly phone meetings.
PASARR Screening Not Completed on Admission
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one resident, R37, on admission. The facility’s policy states that a PASARR must be completed for every resident upon admission and that Social Services will contact the appropriate state agency for referral of specialized care and services as needed. R37 was admitted with diagnoses including mild cognitive impairment and generalized anxiety disorder. The medical record contained a PASARR Level I Screen dated 11/17/25 from a previous stay at the facility, but no PASARR Level I Screen had been completed for the current admission at the time of surveyor review. When the surveyor requested the PASARR documentation, the Nursing Home Administrator stated that R37’s PASARR Level I Screen had been missed. The facility later provided a PASARR Level I Screen that had been completed after the surveyor’s initial request, and it indicated that R37 had a serious mental illness and a 30-day hospital discharge exemption.
Boot Order Not Clearly Followed or Monitored
Penalty
Summary
The facility did not ensure that R37’s removable right walking boot was clearly defined or followed according to the orthopedic orders. R37 was admitted with a right ankle fracture, later had a short leg cast applied, and after the cast was removed was ordered to wear the boot 24/7, with removal allowed only for hygiene and twice for gentle range of motion exercises, while remaining non-weight bearing on the right foot. The order was entered on the July 2026 TAR, but staff interviews showed inconsistent understanding of how often the boot should be removed and how the skin underneath should be assessed. R37 stated that staff had only removed the boot once, and multiple CNAs and an LPN described not removing the boot during baths or skin checks. One CNA said the boot was removed only because it was bothering the resident, while another said nurses handled the boot. A nurse stated they only peeked at the leg once per shift and did not remove the boot to assess the skin. The resident also reported that no one had removed the boot to complete range of motion on the right ankle. The TAR order was reviewed with staff, and the order was identified as needing clarification. When the boot was finally removed during the survey, the resident’s right lower leg, ankle, and foot showed reddened areas, dry and flaky skin, rubbing where the boot met the calf, and other skin changes. The ADON, who was also the wound nurse, stated the boot should have been removed daily for cleaning and inspection and acknowledged the order should have been clarified. A later nursing note documented a small scab with serous crust where the boot was rubbing, a small area with scant serous drainage near the incision, multiple pink blanchable areas, a bruise on the plantar arch, and purple discoloration on the medial foot.
Infection Control PPE and Precaution Signage Failures
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. The deficiency involved two residents, R25 and R7, who were both on precautions requiring specific personal protective equipment (PPE) during care. The facility’s policy stated that transmission-based precautions and enhanced barrier precautions required appropriate PPE use, and that signage outside a resident’s room should clearly indicate the precautions and required PPE. R25 was admitted to the facility and returned from the hospital with a suspected pneumonia diagnosis. R25’s MAR ordered droplet precautions with gown, mask, and gloves every shift, and the care plan also indicated droplet precautions with gown, mask, and gloves. Surveyors observed a facility-made sign outside the room that instructed staff to use hand hygiene and wear a mask, but it did not match the order. An Activity Director entered the room without PPE or hand hygiene, exited, then donned a mask from a PPE cart and re-entered the room. The Activity Director stated they should have worn a mask and were unsure whether a gown or gloves were needed. The Infection Preventionist stated the sign was not clear and staff had questions about what PPE to wear, and the DON stated the sign was old and should be consistent with the resident’s orders and PPE needs. R7 had diagnoses including a stage 4 pressure ulcer of the right hip, neuromuscular dysfunction of the bladder, and urinary device fitting, and had an indwelling catheter and required assistance with personal care. Surveyors observed an EBP sign outside the room directing staff to wear gloves and a gown for high-contact care activities and device care, including urinary catheter care. After an LPN exited the room, the LPN stated they had provided care and wore a gown and gloves, but the resident reported the LPN attempted to obtain a urine sample from the catheter and wore gloves but not a gown. Surveyors observed gloves in the trash but no gown, and the LPN later stated they did not wear a gown during care and should have. The DON verified the LPN should have worn a gown while attempting to obtain the urine sample.
Unsafe Charging of Motorized Scooter Battery
Penalty
Summary
The facility did not ensure a motorized scooter battery was charged in a safe location for R12, a resident with a progressive neurological condition who used a motorized scooter. The facility’s Motorized Assistive Device Policy stated that charging must occur in a designated approved location, away from combustible materials, and is not allowed in resident rooms, exits, or egress pathways. However, surveyors observed a battery charger for R12’s motorized scooter plugged into a wall outlet in R12’s room on multiple observations, with R12 in the scooter. During interview, the DON and ADON stated that R12 preferred to charge the scooter in the room at night, and the DON acknowledged the safety concern.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
Staff failed to timely report an allegation of physical abuse involving two residents. On the morning of 7/24/25, one resident placed their arms around another resident's neck, pulled them closer, and pinched their ear. The affected resident appeared upset and tearful, and staff observed that the interaction was unwanted. Despite witnessing the incident, staff did not report it at the time. The abuse was only reported after a subsequent incident occurred later that same day. Review of facility policy indicated that all alleged violations must be reported within two hours to the State Licensing Agency. Interviews with staff, including an LPN and the DON, confirmed that the initial incident was not reported as required, and the LPN acknowledged that reporting the first occurrence might have prevented the second.
Failure to Complete PASRR Level II Referral After Significant Change in Mental Status
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level II referral after a significant change in mental status for a resident with a history of mental disorder, schizophrenia, major depressive disorder, and cognitive communication deficit. The resident was readmitted with these diagnoses and had a documented severe cognitive impairment, as indicated by a BIMS score of 0 out of 15. A psychiatric evaluation was conducted due to self-injurious behaviors and aggression towards others, resulting in recommendations to adjust the resident's medications and to evaluate the appropriateness of the current level of care. Despite these significant behavioral changes and multiple documented incidents of self-harm and aggression, no PASRR Level II referral was made. Staff interviews revealed that the Social Services Director was aware of the resident's increased behaviors but did not consider the need for a PASRR Level II referral. The Director of Nursing also acknowledged awareness of the behaviors and participation in the psychiatric meeting but was unsure of the PASRR process. The facility's policy requires prompt referral to the state mental health or intellectual disability authority for any Level II resident experiencing a significant change in status, which was not followed in this case.
Resident Fall Due to Failure to Use Gait Belt During Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident without using a gait belt, contrary to the facility's Safe Resident Handling/Transfers Policy. The resident, who had a history of hemiplegia and hemiparesis following a stroke and was on anticoagulant medication, required substantial to maximal assistance with transfers and was care planned to use a walker and one-person assistance. During a transfer from wheelchair to bed, the CNA did not use a gait belt, resulting in the resident falling forward and sustaining a head laceration that required staples. The facility's policies required the use of handling aids such as gait belts during transfers and mandated that staff follow safe handling practices as outlined in each resident's care plan. The resident's care plan and therapy communication sheets prior to the incident did not explicitly state that a gait belt was required for transfers, although staff interviews confirmed that using a gait belt was considered standard practice for pivot transfers. The CNA involved acknowledged forgetting to use the gait belt during the transfer, despite knowing it was required. Interviews with facility staff, including the DON and therapy staff, confirmed that the omission of the gait belt during the transfer was the root cause of the fall. The care plan was not updated to specify gait belt use until after the incident. The resident's medical record and interviews confirmed the injury and subsequent treatment, and staff interviews revealed inconsistencies in the timing and documentation of staff education regarding gait belt use.
Failure to Implement Infection Control Program and Hand Hygiene Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies. Enhanced Barrier Precautions (EBP) were not implemented for a resident with an indwelling urinary catheter upon their return from the hospital. Although the resident's care plan indicated the need for EBP, there was no EBP signage or PPE cart present near the resident's room for several weeks, and staff did not consistently use gowns during catheter care, only gloves. The Director of Nursing confirmed that EBP should have been in place earlier but was missed. Staff were also observed failing to perform appropriate hand hygiene after handling soiled items. A Certified Nursing Assistant (CNA) was seen transporting a soiled diaper, Hoyer sling, and resident's pants to the laundry receptacle without wearing gloves and did not perform hand hygiene after disposing of the items. The CNA then proceeded to assist residents in the dining room and touched common surfaces, such as a touch screen, without cleaning their hands. The CNA later acknowledged that hand hygiene should have been performed after handling soiled items and garbage receptacles. Additionally, residents were not offered hand hygiene prior to meals in the dining room. During a lunch observation, no sanitizing hand wipes were available on tables, and multiple residents were served meals without being offered hand hygiene. Interviews with residents and staff confirmed that hand hygiene was not routinely offered before meals, despite facility policy requiring it. The Director of Nursing and other staff acknowledged that residents should be provided with hand hygiene opportunities prior to eating.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency as required by its Abuse Prevention policy. A resident with dementia, adult failure to thrive, and on palliative care was found to have a hematoma on the left forearm, with staff and Hospice personnel unable to determine the cause of the injury. The resident had a severely impaired cognitive status, as indicated by a BIMS score of 3 out of 15, and an activated Power of Attorney for Healthcare. Progress notes documented the presence of discoloration and a large hematoma, with no complaints of pain from the resident, who was also noted to be combative with staff during care. Despite the facility's policy requiring all alleged violations, including injuries of unknown origin, to be reported to the State Agency within two hours and followed up in writing within five days, the injury was not reported. The facility conducted an internal investigation, which included input from the resident's POAHC, who stated the resident had hit their arms on the bed during a visit. However, the injury remained unreported to the State Agency, and the Director of Nursing confirmed this omission during the surveyor's interview.
Failure to Interview Other Residents During Investigation of Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident with severe cognitive impairment and multiple medical conditions, including dementia and palliative care needs. The resident was found to have discoloration and bruising on both wrists, which staff and hospice personnel noted had appeared and disappeared over several weeks. On a subsequent assessment, a large hematoma was observed on the resident's left forearm. The resident was unable to provide reliable information due to severely impaired cognition, and the activated Power of Attorney for Healthcare was involved in discussions about the resident's care and behaviors. Although the facility initiated an internal investigation by interviewing the resident, all staff who had contact with the resident during the relevant period, and the resident's POAHC, the investigation did not include interviews with other residents as required by the facility's Abuse Prevention policy. The policy specifically directs that investigations of potential abuse or injuries of unknown origin should include interviews with other residents who received care from the same staff. The Director of Nursing confirmed that this step was omitted during the investigation.
Failure to Update Care Plan for Resident's Preferred Name and Skin Protection Measures
Penalty
Summary
A deficiency occurred when the facility failed to update and revise the care plan for a resident in accordance with the resident's current care needs. The resident, who had diagnoses including dementia, adult failure to thrive, and was receiving palliative care, had a severely impaired cognitive status as indicated by a BIMS score of 3 out of 15. Staff interviews revealed that the resident was sometimes called by a shortened version of their name or "grandma" to help calm behavioral episodes. However, a family member objected to the use of "grandma," and after discussion with the resident's POAHC, approval was given for staff to use the term if it was helpful. Despite this, the care plan was not updated to reflect the resident's preferred names. Additionally, the resident sustained an injury of unknown origin, and an investigation determined that the resident, known to be combative, had hit their arms on the bed. In response, geri-sleeves were implemented to protect the resident's skin, in collaboration with hospice staff. However, the care plan was not revised to include the use of geri-sleeves for skin protection. Both the ADON and DON confirmed that the care plan had not been updated to reflect these changes, despite the interventions being in place.
Failure to Provide Required ADL Assistance and Showers
Penalty
Summary
Three residents did not receive necessary assistance with activities of daily living (ADLs) as required by facility policy. One resident, who had severe cognitive impairment, Alzheimer's disease, and was on Hospice care, was observed multiple times in bed in an uncomfortable position, not having been repositioned or checked for incontinence for several hours after the start of the morning shift. The resident's breakfast tray was not set up or assisted with, despite care plan interventions requiring frequent checks and assistance with eating due to a history of aspiration and swallowing issues. Staff interviews confirmed that the resident had not been repositioned, checked, or assisted with eating until late in the morning, and the resident was found incontinent and in need of assistance at that time. Another resident, who was cognitively intact but required substantial assistance with showering and dressing, reported not receiving weekly showers and expressed a desire for more frequent showers. The resident had filed a grievance requesting two showers per week, but the care plan, Kardex, and shower schedule were not updated to reflect this request. Review of documentation showed only six showers were recorded over several months, and staff confirmed that the resident's request and grievance were not properly addressed or implemented in the care planning process. A third resident, with moderately impaired cognition and significant physical limitations including an above-knee amputation, reported not being offered a shower since admission two weeks prior. The resident's care plan and MDS assessment contained conflicting information regarding the level of assistance needed for bathing. No shower sheets, refusal documentation, or skin checks were found for this resident, and staff confirmed that the resident had not received a shower or the required skin assessments since admission. The facility's policies required at least weekly showers and proper documentation, which was not followed in these cases.
Failure to Maintain Resident Dignity and Communication During Mealtimes
Penalty
Summary
Staff failed to maintain resident dignity and provide appropriate communication during mealtimes for three residents who required feeding assistance. One resident waited 16 minutes in the dining room, watching others eat before being served, and did not receive any interaction or acknowledgment from staff during this time. When the resident was finally assisted, the staff member did not introduce themselves, describe the food, apologize for the delay, or engage in any conversation, and left the resident mid-meal for seven minutes without explanation. Two other residents who required feeding assistance were also not spoken to or engaged by staff while being fed. One staff member did not address or converse with a resident throughout the entire meal, and another only began interacting with a resident near the end of the meal. After feeding, staff continued to provide care and move residents without any verbal communication, further neglecting opportunities for interaction and dignity. Interviews with staff and leadership confirmed that some staff do not routinely communicate with residents during meals, especially if the resident is nonverbal or unable to respond. Staff also acknowledged that it is common for residents requiring feeding assistance to wait extended periods before receiving help, and that leaving a resident mid-feeding to assist others occurs depending on staffing and daily circumstances. Facility policies require a pleasant dining environment and sufficient support personnel, but these were not consistently followed during the observed meal service.
Failure to Obtain Court-Ordered Protective Placement for Resident Under Guardianship
Penalty
Summary
The facility failed to ensure that a court-ordered protective placement was obtained for a resident under guardianship after the resident's stay exceeded 60 days. The resident, who had diagnoses including schizophrenia, epilepsy, and major depressive disorder, was unable to complete a mental status interview as indicated by a BIMS score of 0 out of 15. Although a petition for protective placement was present in the medical record, there was no evidence of a final court order for protective placement. The social worker confirmed that only the petition was on file and not the final order, and the nursing home administrator was unaware of the need for protective placement for this resident. The facility typically relied on receiving protective placement paperwork from the guardian or the court, but in this case, the necessary documentation was not obtained after the resident's admission and extended stay.
Failure to Promptly Investigate and Resolve Resident Grievance
Penalty
Summary
A resident with multiple sclerosis and anxiety disorder, who was cognitively intact and responsible for their own healthcare decisions, repeatedly voiced concerns to staff and the Grievance Official about being woken up early in the morning by another resident's yelling. Despite the facility's policy requiring prompt efforts to resolve grievances, including documentation and investigation, the resident's complaint was not formally documented, investigated, or resolved. The Certified Nursing Assistant who received the complaint did not inform others or file a grievance, assuming other staff were aware. The Grievance Official acknowledged receiving the complaint and offering a room change, which the resident declined, but did not document the interaction or initiate a grievance process. Interviews with facility staff revealed uncertainty about when to file a grievance and inconsistent application of the grievance policy. The Social Worker, designated as the Grievance Official, admitted that a grievance should have been filed given the resident's continued distress. The Nursing Home Administrator also indicated that the process for filing grievances depended on the resident's level of upset and was unclear if the resident was offered the opportunity to file a formal grievance. As a result, the facility failed to make a prompt effort to investigate and resolve the resident's grievance as required by policy.
Failure to Ensure Timely and Authorized Medication Administration
Penalty
Summary
Staff failed to provide pharmaceutical services in accordance with facility policy and physician orders for two residents. For one resident with quadriplegia and a history of depression and UTIs, AM and noon medications were administered more than an hour after the scheduled times. The Medication Administration Record (MAR) and staff interviews confirmed that the medications were given late, with the noon dose administered at 2:14 PM, outside the facility's policy of administering medications within 60 minutes of the scheduled time. For another resident with peripheral vascular disease and cellulitis, staff left the resident's morning medications at the bedside for self-administration without a physician order or a completed self-administration assessment. The resident's medical record did not indicate authorization or assessment for self-administration, and the staff member confirmed leaving the medication at the bedside and acknowledged that this was not standard practice. Both incidents were observed and verified through staff interviews and record review.
Failure to Monitor for Adverse Reactions to High-Risk Medication
Penalty
Summary
The facility failed to monitor for adverse reactions or side effects of a high-risk medication, gabapentin, for one resident. The resident had a history of hemiplegia and hemiparesis following a stroke, long-term use of anticoagulants, and was cognitively intact with a BIMS score of 15. The resident was prescribed gabapentin 400 mg to be taken three times daily for neuropathic pain and restless leg syndrome. Despite the known potential side effects of gabapentin, including serious reactions, the resident's medical record did not contain any documentation of monitoring for adverse reactions or side effects. This lack of monitoring was confirmed by the DON upon review of the resident's medical record during the survey.
Failure to Report Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to report an allegation of neglect to the State Agency (SA) concerning a resident who experienced a fall with a major injury. The resident, who had severe cognitive impairment and was under hospice care, fell in their room and sustained a right femoral neck fracture. The resident's care plan included an intervention for a sensor alarm on their bed, but the facility's fall investigation revealed that the alarm was not in place at the time of the fall. Despite this inconsistency with the care plan, the facility did not report the potential neglect to the SA. The fall occurred in the early morning, and the resident was found on the floor with the bed in a low position and a floor mat in place. Staff interviews conducted during the investigation showed conflicting accounts regarding the use of a bed alarm for the resident. Approximately half of the staff recalled a bed alarm being used, while the other half did not. The facility's Regional Administrator acknowledged that the investigation identified inconsistent use of the bed alarm but did not classify the incident as neglect, leading to the failure to report it to the SA.
Failure to Implement Sensor Alarm Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the provision of an assistive device, specifically a sensor alarm, to prevent accidents for a resident with a history of falls. The resident, who had severe cognitive impairment and was at risk for falls, had a care plan that included the use of a sensor alarm on their bed. However, during an incident where the resident sustained a fall with injury, the sensor alarm was not in place. This oversight occurred despite the care plan's clear directive for the use of the alarm as a precautionary measure. Interviews and record reviews revealed inconsistencies in staff awareness and implementation of the sensor alarm intervention. Approximately half of the staff interviewed remembered the use of a bed alarm for the resident, while the other half did not recall ever seeing it in use. The Regional Administrator confirmed that the sensor alarm was not in place at the time of the fall, verifying the deficiency in adhering to the resident's care plan. This lapse in following the established intervention contributed to the resident's fall and subsequent injury.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 34 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clintonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pines Post Acute And Memory Care | 4.7 mi | ★★★★★ | 0 | 0 |
| Shawano Health Services | 11.7 mi | ★★★★★ | 14 | 0 |
| Evergreen Health Services | 12 mi | ★★★★★ | 0 | 0 |
| Birch Hill Health Services | 12.3 mi | ★★★★★ | 13 | 0 |
| Manawa Com Nur Ctr | 14.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.