Greenfield Care Center of Fillmore, LLC

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to maintain privacy and right for one of 19 residents sampled (Resident 1) on Enhanced Barrier Precautions (EBP an infection control strategy in nursing homes) inicated by foley catheter ( a flexible, indwelling tube inserted through the urethra into the bladder to drain urine ) and G-tube (gastrostomy tube - a flexible tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications) when care was provided in the activity room in presence of other resdients. This facility failure has the potential to lead to resident's decline in mental health and a decline in overall physical well-being During an observation on 3/18/26 at 4:00 p.m., in the dementia care unit activity room. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure information regarding a Physician Orders for Life-Sustaining Treatment (POLST-physician orders indicating the patient's wishes during a medical crisis, such as cardiopulmonary resuscitation [CPR], and/or artificial nutrition/hydration [receiving food and water through a tube], was provided to one of nineteen sampled residents (Resident 3) or the legally recognized decisionmaker. This failure results in the unsigned POLST to be invalid and had the potential to cause uncertainty among healthcare staff regarding the resident's personal preferences with end of life care. During review of Resident 3's Physician Orders for Life-Sustaining Treatment (POLST) form dated 2/11/23, the POLST indicated orders to Attempt Resuscitation/CPR, full treatment, and use of long-term artificial nutrition including feeding tubes. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written information to one of nineteen sampled residents (Resident 37) about a bed-hold (a reservation that allows one to stay in, or return to, a care facility) when Resident 37 was transferred to a hospital. This failure had the potential of Resident 37 not being fully informed of their right to request a bed hold and to return to the facility after hospitalization, potentially leading to an inappropriate discharge. ( I am not sure, if we can write this because the both hospital SNF know about the 7 day hold and there was no outcome. [...]

Inspectors wroteBased on interview and record review, the facility failed to resubmit a Preadmission Screening and Resident Review (PASRR - a tool to determine if the person had or was suspected of having a mental illness or intellectual disability) for two out of nineteen sampled residents (Resident 5 and Resident 45) when the residents were diagnosed with a new mental illness. This failure had the potential to result in Resident 5 and Resident 45 to not receive the appropriate medical services for their mental illness diagnoses. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure a care plan (CP - written document that outlines the specific nursing interventions and goals for a patient's care, based on their assessed needs and diagnoses) pertaining to noncompliance with dialysis was reviewed, evaluated for effectiveness, and revised accordingly for one out of the nineteen sampled residents ( Resident 3). This deficient practice has the potential to place Resident 3 at significant risk for hospitalization, severe cardiovascular events, and even death due to unmet medical needs. During a review of Resident 3's Order Summary (OS), 3/20/26, the OS indicates, Resident #3 goes to dialysis every Tuesday, Thursday and Saturday. [...]

Inspectors wroteBased on interview, intervview and facility policcy and procedure, the facility failed to ensure timely wound assessment assessment was done for one of nineteen sampled residents (Resident 7) when there were no documentation to show track changes in size, tissue type, moisture levels, and infection signs, on certain weeks. This failure had the potential to affect treatment plans and delay healing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:Expired items in the medication storage room were disposed of according to policy and procedures and manufacturer's instructions. Treatment medications and medical supplies in the treatment cart were properly labeled and expired medication and supplies were discarded. The temperature for station 3 medication refrigerator was within acceptable range. These failures had the potential for residents to receive expired medications and and ineffective treatment supplies.1. During a concurrent observation and interview on 3/18/26 at 2:25 p.m. with Registered Nurse Supervisor (RNS), the medications inside the refrigerator located in the respiratory storage room were inspected. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain essential kitchen equipment on the ice machine clean and in safe operating condition. This failure has the potential to expose residents to contaminated ice and increased risk for food related illnesses. During an observation and insepction of the ice machine on 03/18/26 at 2:36 pm at the kitchen, a white tissue test was performed on the lower bin made of stainless steel inside the ice machine. After wiping the base of the bin, the white tissue contains a minimal amount of greyish-black residue. Repeating the procedure further back into the bin also showed minimal greyish residue. The Dietary Manager (DM), Maintenance Representative (MR) and Dietician (DIET) validates the findings. [...]

Inspectors wroteFacility failed to practice infection control when: 1. appropriate Personal Protective Equipment (PPE: clothing and equipment used in order to provide protection against hazardous substances or environments) for enhanced barrier precautions (EBP: an infection control strategy for nursing homes requiring staff to wear gowns and gloves during high contact care of residents) was not worn for two residents, Resident 1 and Resident 2.2. respiratory tubes were not changed in a timely manner for Resident 25 and 3. the facility failed to discard open or used saline bottles found in medication carts and de-cloggers (a flexible, threaded rod used to restore the patency [openness] of obstructed enteral feeding tubes). This failure had the potential to expose residents for further infection and contamination. 1. During a concurrent observation and interview on 3/18/26 at 10:31 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive and individualized plan of care (care plan) for 3 of 20 Sampled residents ( Resident 35, 11 and 47) when: 1. Resident 35's preference for communicating. 2. Resident 11's alarming devices on a wheelchair and bed. 3. Resident 47's need for the appropriate communication device based on physical condition . These failures had the potential for not meeting resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards when : 1. Resident 719 supplemental oxygen was administered without a physician order. 2. Acetylcysteine (an oral inhalation used to help with breathing) was not administered as ordered by the physician for one of four sampled residents (Resident 27). 3. A respiratory therapist (RT1) failed to follow the facility's policy and procedure on medication administration ( nebulizer /aerosol medication) and documentation for one of four sampled residents (Resident 27). 4. Resident 4's insulin (a medication to lower blood sugar levels) was not administered per physician's ordered insulin sliding scale parameters. 5. Resident 4's insulin medication was not administered in a timely manner. [...]

Inspectors wroteBased on inspection of the facility's Medication storage room on Unit 3, interview with the facility's IP, and review of the facility's policy and procedures the facility failed to: 1. follow their policy and procedure for sharps waste, 2. ensure that Emergency Drug supplies (E-Kits), had not been opened for more than 72 hours as outlined in the facility's policy and procedure, 3. ensure that no expired medications were available for use, 4. ensure that medications were administered in accordance with the hospital's policies and procedures and 5. ensure that medications are immediately documented in the Medication Administration record (MAR) after the administration of medications to a resident.

Inspectors wroteBased on Medication Pass observation, review of the resident's Medication Administration Record (MAR) and Physician's orders, Two out of two medication nurses observed for a total of 45 medication pass opportunities. Out of these 45 medication pass opportunities, there were a total of 8 medication errors which were observed. These 8 medication errors resulted in an overall medication error rate of 17.7% for the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the exhaust hoses of the portable air conditioning units (PACU) were properly installed as directed (not duct taped to the window frames) and filters were routinely cleaned according to manufacturer's guidelines (MFU) in 12 of 12 PACU's found inside Rooms 15, 20,21,22,23,24,25,26,27,28,30, and 32. This failure had the risk for entrapment in the event of a fire secondary to the windows becoming inoperable due to exhaust hoses duct taped to the window frames, with the potential for poor air quality as filters were not cleaned as directed.

Inspectors wroteBased on observation, interview and record revie and facility policy and procedure, the facility failed to ensure Interdisciplinary Team (IDT- a group of healthcare professionals from various disciplines who collaborate to provide comprehensive, patient-centered care) assessed resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for 1 of 20 sampled residents (Resident 51). This failure can result with resident not taking the medication correctly.

Inspectors wroteBased on observation interview and record review, the facility failed to have the most current survey results accessible to the public, in the facility survey results binder. This facility failure denied the opportunity for residents, family members, and legal representatives of residents, to be aware of the most recent survey results.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess 2 of 20 sampled residents (Resident 35 and 39) using the Minimum Data Set (MDS - a standardized tool used to assess and plan care of residents in a nursing home) when: 1. Resident 35 - had an inaccurate language assessment. 2. Resident 39 - had an inaccurate functional status assessment. These failures resulted in the facility reporting inaccurate data to Centers for Medicare & Medicaid Services (CMS) that does not reflect Resident 35 and 39 statuses in MDS assessment.

Inspectors wroteBased on review of the facility's medication refrigerator logs, review of the facility's policy and procedures, and interview with the facility's I P Nurse the facility failed to ensure that the refrigerator temperatures had been documented and remained within the temperature requirements as outlined by the facility's policy and procedure.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow policies and procedures for labelling and dating foods. This failure has the potential for Foodborne illnesses (infections or intoxications caused by consuming contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control practices when: 1. Respiratory care equipment was not stored properly after use by Residents (4 and 27) 2. Oxygen plastic tubing and nasal cannula were not labelled according to the facility's policy for one of four residents (Resident 27). 3. Personal protective equipment (PPE) was not available prior to entering resident rooms on contact precautions in rooms [ROOM NUMBERS]. These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable Healthcare Associated Infections (HAI) for residents with compromised condition.

Inspectors wroteBased on record review and interview, the facility failed to document its response and resolution on the recurring complaints of call lights not being answered in a timely manner raised by residents at its Resident Council Meetings for two consecutive months. This failure put the residents at risk of receiving poor and unmonitored care, with the possibility of the issues continuing.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a total dependent resident (Resident 1) received necessary treatment and services, to promote healing, and prevent new pressure ulcers (deep tissue injury) from developing. This facility failure resulted in Resident 1 acquiring a new stage 3 pressure ulcer (full thickness tissue loss) to the right buttock.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement comprehensive person-centered care plans (CP) with regard to the Restorative Nursing Assistant (RNA- provides support and assistance to patients in their recovery and maintenance of physical function) program for fourteen sampled residents (Resident 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16). These failures increased the potential for Residents 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16 to not receive treatment and care according to their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate supervision and assistance was provided for one of three sampled residents (Resident 1) to prevent avoidable accident and injury. This failure resulted in, Resident 1 fell on the floor and sustained a right distal (further from the trunk of the body) femur (thighbone) fracture (partial or complete break in the bone).

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing professional standards of care for one of two sampled residents (Resident 1) when: 1. A graft site discharge order was not followed up with the admitting physician. 2. Removal of the sutures from a post tracheostomy (surgical procedure that help with breathing through an opening on the neck) site was not obtained per facility policies and procedures. 3. Skin assessment was not accurately done upon admission ([NAME]-coccyx (tail bone)redness, right side open area on the neck). These failures had the potential and risk for Resident 1 to develop further skin breakdown, and infections from unmonitored skin areas with issues.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) had an accurate documentation of Resident 1 ' s tracheostomy (a procedure that help with breathing through an opening on the neck) site skin condition. This failure had the potential for Resident 1 ' s skin condition to be unmanaged and posed a risk for the delay in treatment.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprensive person-centered care plan (document that provides the resident's condition, diagnosis and the nursing team's goals) for one of three residents (Resident 1), when Resident 1 had a new onset of right leg redness and swelling and required medical treatment. This failure had the potential for Resident 1's care needs to go unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions of a smoking care plan and ensure adequate supervision and assistance were provided as assessed for one of three sampled residents (Resident 1). This failure resulted in Resident 1 smoking by himself off the facility premises and falling from the wheelchair to the ground sustaining an acute fracture of the left humerus (partial or complete break in the bone, upper arm between shoulder and elbow).

Inspectors wroteBased on observation, interview, and record review, the facility failed to repair a loose, broken handrail in the hallway of station three (3) where three sampled residents (Residents 10, 21, 10) and 16 unsampled residents, resides. This failure placed the residents at risk for injuries and accidents.

Inspectors wroteBased on observation, interview, record review, the facility failed to follow professional standards of nursing practice for 2 of 16 sampled residents (Resident 52 and 63) when: 1. Licensed Nurse (LN3) flushed the gastrostomy tube (G-tube - a tube inserted through the abdomen that delivers nutrition directly to the stomach) of Resident 52, with 10 milliliters (ml) of water in between medication administration with no physician orders or standard of practice reference. This failure can result to the clogging of the GT or less water intake of the resident which can be both detrimental to the resident's overall condition . 2. Resident 63's head-of-the-bed was not elevated ( at 30 degrees high instead of 45 ) enough, while the resident's feeding formula was infusing via G-tube. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were locked, and inaccessible to unauthorized staff, residents, and visitors when medications were left on top of a treatment cart (large capacity, flexible organization and simple maneuverability for easy transport and storage of medical or treatment supplies) unattended. This failure had the potential for visitors, residents, and unauthorized staff to access prescription medication assigned to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a cook had the skill set to calibrate a food thermometer ( gadget to measure food themperature) to verify appropriate and acceptable food temperatures. This failure had the potential to place residents at risk for developing foodborne illness (food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu and/or resident's individualized meal tray card as planned when: 1. The portion size for one pureed item did not match the menu for one of 16 sampled residents (Resident 14). 2. The small portion size directions listed on Resident 44's meal tray card was not honored during lunch trayline ( A system of food preparation in which trays move along an assembly line) in the kitchen. 3. A diet order that included chopped was not followed during lunch trayline in the kitchen for one of 16 sampled residents (Resident 4). This facility failure had the potential to not meet the resident's nutritional needs per the planned menu as approved by the facility's Registered Dietitian. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the fans inside the walk-in refrigerator were maintained in a sanitary manner. This failure had the potential to cause cross contamination and place residents at risk for developing a foodborne illness (Illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on interview and record review, the facility failed to assess one of two sampled residents (Resident 1) for the safe handling and use of an electronic cigarette (a cigarette-shaped device containing a nicotine-based liquid that is vaporized and inhaled, used to simulate the experience of smoking tobacco). This facility failure had the potential for Resident 1 to experience negative outcomes.