Greene Health & Rehab: Pain Management Failure - PA
That is what federal inspectors found at Greene Health & Rehab Center following a complaint inspection completed September 5, 2025.
Resident 4, described in inspection records as cognitively intact and able to communicate clearly, had been on a standing order for 650 milligrams of Tylenol three times a day since November 2024. On August 28, 2025, staff documented in the physician's communication book that she had swelling, couldn't sleep, and was experiencing increased pain.
The next day, a Doppler test confirmed she had a deep vein thrombosis, a blood clot, in her left lower leg. She received new orders for Eliquis, a blood thinner, twice daily.
Four days later, at 4:47 in the morning on September 2, the pain had become something else entirely.
A nursing note from that shift recorded that the resident was "having a lot of pain this shift that was not relieved with her scheduled Tylenol." She was complaining of her leg and her back. She cried out if she was moved. When staff tried to reposition her, she yelled at them to stop touching her leg. She cried multiple times that she just wanted to die and didn't understand why she had to live in such pain.
Staff placed a note in the physician's communication book requesting comfort care, stronger pain medication, or hospice.
Nobody called the doctor.
The inspection report found no documented evidence in the clinical record that the physician was contacted that morning for additional interventions or treatment. The note sat in the book, waiting for the physician's next visit.
The facility's own pain management policy, updated as recently as July 22, 2025, stated that a physician or provider would be notified of a new onset of pain or a significant increase in pain. A resident with a confirmed blood clot, screaming when touched, weeping that she wanted to die, represented exactly that situation. The policy described acute pain as sudden in onset, time-limited, often caused by injury or medical treatment. A DVT fits each of those descriptions.
The gap between what the policy required and what staff did that morning was the central finding of the inspection.
When the Director of Nursing sat down with inspectors on the afternoon of September 5, she confirmed it plainly. Resident 4's acute pain was not controlled, she said, and it should have been.
The deficiency was cited at a level of minimal harm or potential for actual harm, the lower end of the federal harm scale. That classification reflects the regulatory framework inspectors apply, not necessarily the experience of a woman lying awake before dawn, crying that she wanted to die, while staff wrote her a note they hoped someone would read later.
Deep vein thrombosis causes significant pain on its own. The clot creates pressure and inflammation in the affected limb, and movement can intensify that pain sharply. Tylenol, effective for mild discomfort, is not typically sufficient for the pain associated with an acute DVT. The resident had been telling staff this, in the clearest possible terms, for days.
Greene Health & Rehab Center is located at 119 Industrial Park Road in Greensburg. The inspection was conducted in response to a complaint. The single deficiency cited covered nursing services under Pennsylvania's Department of Health code.
The record does not say whether anyone called the physician later that day, or the day after. It does not say whether Resident 4 received stronger pain medication before inspectors arrived. It says she cried that she wanted to die, and that a note was placed in a book, and that the physician was not contacted at that time.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greene Health & Rehab Center from 2025-09-05 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Greene Health & Rehab Center in GREENSBURG, PA was cited for violations during a health inspection on September 5, 2025.
That is what federal inspectors found at Greene Health & Rehab Center following a complaint inspection completed September 5, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.