Greentree Health And Rehabilitation Center

Inspection findings

1. Oct 9, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Nov 25, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0646 Resident Assessment and Care Planning Deficiencies

     Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

     Corrected Nov 25, 2025 · CMS health inspection

2. Apr 23, 2025 Health · 15 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0551 Resident Rights Deficiencies

     Give the resident's representative the ability to exercise the resident's rights.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0585 Resident Rights Deficiencies

     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.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected May 9, 2025 · CMS health inspection

   • Serious Scope/severity G

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected May 2, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 2, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected May 2, 2025 · CMS fire safety

3. Sep 11, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Oct 7, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Oct 7, 2024 · CMS health inspection

4. Feb 21, 2024 Health · 10 findings
   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Feb 25, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0232 Egress Deficiencies

     Have corridors or aisles that are unobstructed and are at least 8 feet in width.

     Corrected Mar 15, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0311 Smoke Deficiencies

     Have an enclosure around a vertical opening shaft.

     Corrected Mar 15, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Mar 15, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Mar 15, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0354 Smoke Deficiencies

     Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

     Corrected Mar 15, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Mar 15, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Mar 15, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Mar 15, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Mar 15, 2024 · CMS fire safety

5. Feb 15, 2023 Fire Safety · 8 findings
   • Not serious Scope/severity F

     E0036 Emergency Preparedness Deficiencies

     Establish emergency prep training and testing.

     Corrected Mar 14, 2023 · CMS fire safety

   • Not serious Scope/severity D

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Mar 14, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Mar 7, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0685 Quality of Life and Care Deficiencies

     Assist a resident in gaining access to vision and hearing services.

     Corrected Mar 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0806 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

     Corrected Mar 7, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Mar 14, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected May 4, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 14, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 12/20/2013
• BURNAM, SOON — managing control - governing body, NOT APPLICABLE, since 01/01/2022
• KAMIN, SHAYNA — adp of the snf, NOT APPLICABLE, since 06/27/2025
• KAMIN, SHAYNA — operational/managerial control, NOT APPLICABLE, since 11/01/2024
• KAMIN, SHAYNA — managing control - governing body, NOT APPLICABLE, since 11/01/2024
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• NEAS, MARISSA — managing control - governing body, NOT APPLICABLE, since 06/01/2014
• NEAS, MARISSA — adp of the snf, NOT APPLICABLE, since 06/27/2025
• NEAS, MARISSA — operational/managerial control, NOT APPLICABLE, since 06/01/2014
• PORT, BARRY — corporate director, NOT APPLICABLE, since 01/01/2022
• DEER CREEK HEALTH HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 01/01/2022
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 01/01/2022
• J THOMPSON STAFFING INC — operational/managerial control, NOT APPLICABLE, since 06/01/2014
• PRN HEALTH SERVICES, INC. — operational/managerial control, NOT APPLICABLE, since 06/01/2014
• STANDARD BEARER HEALTHCARE OP, LP — adp of the snf, NOT APPLICABLE, since 01/01/2022
• THE ENSIGN GROUP INC — adp of the snf, NOT APPLICABLE, since 01/01/2022