Health inspection·September 23, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for one of 14 residents reviewed (Resident 6).Findings include:The facility's pressure injury prevention and treatment policy, dated July 22, 2025, revealed that identified pressure injuries would be documented on and orders obtained from providers for treatment.An admission MDS for Resident 6, dated September 11, 2025, revealed that the resident was cognitively intact, required assistance for daily care needs, and was at risk for developing pressure ulcers. A care plan for Resident 6, dated September 15, 2025, revealed that the treatments to the sacral wound were to be applied per physician orders.A wound consultation for Resident 6, dated September 12, 2025, revealed that the resident had an unstageable pressure ulcer (non-stageable due to coverage of wound bed by slough and/or eschar) to her sacral area (lower tailbone) that measured 5.7 x 5.5 centimeters (cm). Physician's orders for Resident 6, dated September 12, 2025, included an order for the resident to receive Triad cream (medicine used to maintain a moist environment to promote wound healing) to her sacral wound every shift. Review of the Treatment Administration Record (TAR) for Resident 6, dated September 2025, revealed that Triad cream was applied to the resident's sacral wound daily from September 12 through 15, 2025.Interview with the Assistant Director of nursing on September 23, 2025, at 12:46 p.m. confirmed that the treatment to resident's sacral wound was not applied every shift as ordered by the physician. 28 Pa. Code 211.12(d)(5) Nursing services.see above Residents Affected - Few Page 1 of 3 395604 395604 09/23/2025 Greene Health & Rehab Center 119 Industrial Park Road Greensburg, PA 15601

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat as ordered by the physician for one of 14 residents reviewed (Resident 12). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated September 4, 2025, indicated that the resident was cognitively intact, required set-up assistance from staff with eating, and had diagnoses that included hemiplegia and hemiparesis following cerebral infarction (paralysis or weakness to one side of the body due to brain injury). An occupational therapy note for Resident 12, dated September 19, 2025, indicated that the resident was to continue the use of a divided plate (plate that allows easier access to food) with dycem (a non-slip mat used to keep items in place) underneath and left angled black ridged non weighted utensils (designed to assist individuals with limited mobility, hand tremors, or dexterity issues). A dietary slip was completed. Physician's orders for Resident 12, dated September 19, 2025, included an order for the resident to utilize a divided plate with dycem underneath and left angled Black ridged non weighted utensils for all meals, as resident tolerates. Observations of Resident 12 during the lunch meal on September 23, 2025, at 12:06 p.m. revealed that the resident was in his room and did not have a divided plate or the left angled black ridged non weighted utensils.The resident, and the resident's sister, who was present in the resident's room at that time, indicated he was to have the divided plate, and the left angled Black ridged non weighted utensils. The resident had indicated that he uses the edge of the divided plate to assist with getting the food onto his spoon and fork. Interview with the Dietary Manager on September 23, 2025, at 12:54 p.m. indicated that Resident 12's adaptive equipment for the built-up utensils and divided plate were discontinued, and he was not listed on her dietary sheet of residents with adaptive equipment. Interview with the Dietary Manager on September 23, 2025, at 1:07 p.m. confirmed that she had a dietary communication sheet for Resident 12, dated September 19, 2025, that indicated to continue the divided plate with dycem underneath and left angled Black ridged non weighted utensils for all meals, as resident tolerates. She confirmed that Resident 12 should have had the divided plate, and the left angled Black ridged non weighted utensils, and he did not. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated September 4, 2025, indicated that the resident was cognitively intact, required set-up assistance from staff with eating, and had diagnoses that included hemiplegia and hemiparesis following cerebral infarction (paralysis or weakness to one side of the body due to brain injury). An occupational therapy note for Resident 12, dated September 19, 2025, indicated that the resident was to continue the use of a divided plate (plate that allows easier access to food) with dycem (a non-slip mat used to keep items in place) underneath and left angled black ridged non weighted utensils (designed to assist individuals with limited mobility, hand tremors, or dexterity issues). A dietary slip was completed. Physician's orders for Resident 12, dated September 19, 2025, included an order for the resident to utilize a divided plate with dycem underneath and left angled Black ridged non weighted utensils for all meals, as resident tolerates. Observations of Resident 12 during the lunch meal on September 23, 2025, at 12:06 p.m. revealed that the resident was in his room and did not have a divided plate or the left angled black ridged non weighted utensils.The resident, and the resident's sister, who was present in the resident's room at that time, indicated he was to have the divided plate, and the left angled Black ridged non weighted utensils. The resident had indicated that he uses the edge of the divided plate to assist with getting the food onto his spoon and fork. Interview Residents Affected - Few 395604 Page 2 of 3 395604 09/23/2025 Greene Health & Rehab Center 119 Industrial Park Road Greensburg, PA 15601

F 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with the Dietary Manager on September 23, 2025, at 12:54 p.m. indicated that Resident 12's adaptive equipment for the built-up utensils and divided plate were discontinued, and he was not listed on her dietary sheet of residents with adaptive equipment. Interview with the Dietary Manager on September 23, 2025, at 1:07 p.m. confirmed that she had a dietary communication sheet for Resident 12, dated September 19, 2025, that indicated to continue the divided plate with dycem underneath and left angled Black ridged non weighted utensils for all meals, as resident tolerates. She confirmed that Resident 12 should have had the divided plate, and the left angled Black ridged non weighted utensils, and he did not. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 395604 Page 3 of 3