Greentree Manor Nursing And Rehabilitation Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
South pod exit door, although the staff had heard the emergency door alarm going off. The DON identified a statement provided by the Food Service Director identified on 11/26/25 at 1:15 PM, he observed a nurse aide (NA #1) bring Resident #1 through the front door, heard the front door alarm go off because of Resident #1's wanderguard and turned off the front door alarm and then the Food Service Director checked all the doors. The DON stated the Food Service Director saw the South pod exit door had a green light, which indicated Resident #1 had exited out that door, and the Food Service Director then pushed on the door, opened it, and reset the door because the alarm was going off. The DON identified staff did not exit out the South pod door immediately following the alarm being set off, which staff were expected to do, and indicated staff did not know the code to reset the exit door alarm. Interview with RN #1 on 12/22/25 at 1:17 PM identified she was notified on 11/26/25 that an off-duty nurse aide (NA #1) brought Resident #1 into the building through the front doors after Resident #1 was found unattended in his/her wheelchair outside the building. RN #1 indicated the temperature was in the mid-sixties and Resident #1 was wearing long pants,
a sweater, and sneakers. RN #1 indicated following the incident Resident #1 was assessed, no injuries were noted, Resident #1's doctor and responsible party were notified, and education was initiated the same day for all staff. RN #1 identified facility policy indicated staff were responsible for checking the alarm, checking the area, and making sure no one was outside the area. Although requested, facility policies for Missing Resident/Elopement and for Wanderguard/Secured Exit were not provided.
Event ID:
Facility ID:
If continuation sheet
GREENTREE MANOR NURSING AND REHABILITATION CENTER in WATERFORD, CT inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WATERFORD, CT, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GREENTREE MANOR NURSING AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.