Greentree Health And Rehabilitation Center
Greentree Health and Rehabilitation Center in Clintonville, WI — inspection on October 9, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of a Misconduct Incident Report provided by the facility, dated 7/30/25 at 2:36 AM, indicated that while investigating an incident between R1 and R2 on 7/24/25 at approximately 3:55 PM, the facility discovered another incident that occurred that morning at approximately 6:30 AM.
The incident was witnessed by staff but not reported.
During an interview on 10/9/25 at 11:28 AM, Licensed Practical Nurse (LPN)1 stated on the morning of 7/24/25 at approximately 6:30 AM, R2 was tearful when another staff informed LPN1 they saw R1 pinch R2's ear. LPN1 said R1 put R1's arms around R2's neck and pulled R2 toward R1.
When R2 became upset about the interaction, R1 pinched R2's ear. LPN1 stated LPN1 observed R2 who appeared upset and did not want the interaction to occur. LPN1 stated the residents were separated, however, LPN1 did not report the abuse it until it happened again that afternoon. LPN1 agreed LPN1 should have reported the first occurrence which may have prevented the second occurrence.
During an interview on 10/9/25 at 1:13 PM, the Director of Nursing (DON) stated staff should have reported the incident that occurred on the morning of 7/24/25.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/09/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Greentree Health and Rehabilitation Center
70 Greentree Rd Clintonville, WI 54929
SUMMARY STATEMENT OF DEFICIENCIES
Review of R1's State of Wisconsin Department of Human Services Pre-admission Screening and Resident Review (PASARR) Level I Screen, dated 3/24/24, indicated R1 did not meet the criteria for Level II because R1 did not meet the criteria for sections two and three.Review of R1's Psychiatric Evaluation, dated 7/23/25, indicated R1 was evaluated due to behaviors including self-injurious behavior and hitting and pinching others.
The evaluation contained recommendations to increase divalproex (anticonvulsant medication) and quetiapine (antipsychotic medication) and evaluate the appropriateness of R1's current level of care.
Review of Progress Notes between May 2025 and October 2025 indicated R1 had 16 documented incidents of self-harm, 11 incidents of aggression toward staff, 4 incidents involving other residents, and 9 incidents of different behaviors.
During an interview on 10/9/25 at 2:09 PM, the Social Services Director (SSD) was aware of R1's increase in behaviors, however, it did not occur to her to check if R1 needed a PASARR Level II referral.
During an interview on 10/9/25 at 1:13 PM, the Director of Nursing (DON) stated she attended R1's July psych meeting.
The DON stated 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.
The DON was unsure of the PASARR process.
Facility ID: