The resident, identified as R1 in inspection records, also had four incidents involving other residents and nine additional behavioral episodes between May and October 2025. A psychiatrist who evaluated the resident in July recommended increasing two psychiatric medications and reviewing whether the nursing home provided an appropriate level of care.
Nobody at Greentree acted on that recommendation.
Federal regulations require nursing homes to complete a Preadmission Screening and Resident Review when residents with mental disorders experience significant changes in condition. The screening, known as PASRR Level II, determines whether residents need specialized mental health services or different placement.
R1's psychiatric evaluation on July 23 documented "self-injurious behavior and hitting and pinching others." The psychiatrist recommended increasing divalproex, an anticonvulsant medication, and quetiapine, an antipsychotic drug. The evaluation also recommended assessing "the appropriateness of R1's current level of care."
The Social Services Director told inspectors on October 9 that she knew about R1's increased behaviors. But "it did not occur to her to check if R1 needed a PASARR Level II referral."
The Director of Nursing attended R1's psychiatric meeting in July. She confirmed the facility was "aware of R1's behaviors, had been trying to address them, and was in the process of finding alternate placement for R1." But she was "unsure of the PASARR process."
R1 was readmitted to Greentree with diagnoses including mental disorder, schizophrenia, major depressive disorder, and cognitive communication deficit. A September assessment showed R1 scored zero out of 15 on a brief mental status exam, indicating severe cognitive impairment.
The facility's own policy, dated July 2024, states that any resident who experiences a significant change in status "will be referred promptly to the state mental health or intellectual disability authority for additional resident review." Examples include residents who demonstrate "increased behavioral, psychiatric, or mood-related symptoms."
The policy also requires referrals when a resident's "condition or treatment is or will be significantly different from that described in the resident's most recent PASRR Level II evaluation and determination."
R1's most recent Level I screening from March 2024 determined the resident didn't meet criteria for Level II evaluation. That was more than a year before the documented spike in violent and self-injurious behavior.
Progress notes between May and October 2025 paint a disturbing picture of escalating incidents. Beyond the 16 episodes of self-harm, staff documented 11 separate occasions when R1 became aggressive toward employees. The resident also had confrontations with four other residents and nine additional behavioral incidents that didn't fit the other categories.
The psychiatric evaluation in July came after this pattern of violence had already begun. Yet administrators took no steps to determine whether R1 needed specialized mental health services or a different level of care, despite the psychiatrist's explicit recommendation to evaluate placement appropriateness.
The PASRR program exists to ensure that individuals with mental disorders receive care in the most integrated setting appropriate to their needs. When nursing home residents with psychiatric conditions experience significant changes, the screening helps determine whether they need additional mental health services or transfer to facilities better equipped to handle their conditions.
R1's case suggests a breakdown in this safety net. The resident experienced what any reasonable observer would consider a significant change in condition – dozens of documented incidents of violence and self-harm over five months, followed by a psychiatric evaluation recommending medication increases and care level review.
The Director of Nursing's admission that she was "unsure of the PASRR process" raises questions about staff training at Greentree. Federal regulations require nursing homes to coordinate with state mental health authorities when residents experience psychiatric deterioration.
The Social Services Director's statement that "it did not occur to her" to check referral requirements suggests a fundamental gap in understanding federal compliance obligations. Her role typically includes coordinating mental health services and ensuring appropriate screenings.
Meanwhile, R1 continued to harm themselves and others while administrators searched for "alternate placement" without completing the evaluation designed to determine what type of placement would be appropriate.
The inspection occurred on October 9, nearly three months after the psychiatric evaluation that should have triggered a PASRR referral. By then, the pattern of violence and self-injury had continued for at least five months, with no indication that the required screening would ever be completed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greentree Health and Rehabilitation Center from 2025-10-09 including all violations, facility responses, and corrective action plans.
Additional Resources
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