Greenfield Health & Rehab Center

Inspectors wroteBased on interview and record review conducted during a survey the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than two (2) hours after the allegation is made, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law for one (1)(Resident #1) of three (3) residents reviewed for abuse. Specifically, an allegation of witnessed staff to resident abuse was not reported to the administrator immediately and to the State agency within the required time frames.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 08/08/2025, the facility did not ensure residents were free from unnecessary drugs for one (1) (Resident #157) out of five (5) residents reviewed. Specifically, Resident #157's psychotropic medication (Xanax, an anti-anxiety medication) dose was increased erroneously and without evidence of adequate indications.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 08/08/2025, the facility did not ensure that residents who had a catheter (tube inserted into the bladder) received the appropriate care and services for one (1) (Resident #113) of three (3) residents reviewed. Specifically, infection control practices were not maintained, and they were not provided with a urinary leg bag as they preferred and per facility practices. The finding is: Review of the policy titled Bladder Indwelling Urethral Catheter Site and Equipment Care dated 2/2024 documented drainage bag holders were available for all residents with Foley catheters. They were to be used if the resident does not use a leg bag. The Foley bag and tubing were placed inside the bag. Never let the tubing hang below the bag. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 8/8/25, the facility did not ensure parenteral fluids were administered with professional standards of practice and in accordance with the physicians' orders, and the comprehensive person-centered care plan for one (1) (Resident #174) of one (1) resident reviewed for intravenous (IV) therapy. Specifically, there was a delay in the administration of intravenous (IV) antibiotics per the final hospital discharge summary, and a lack of orders to address central venous catheter (a long thin tube inserted into a large vein to provide long term access for medication, fluids, or blood draws; right internal jugular vein) maintenance and care (normal saline flushes and dressing changes). [...]

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 08/08/2025, the facility did not ensure the Binding Arbitration Agreement explicitly granted the resident and their representative the right to rescind the agreement within 30 calendar days of signing the agreement for three (3) (Resident #104, #118 and #152) of three (3) resident reviewed for the arbitration task. Specifically, the facility's Binding Arbitration Agreement stated the resident/representatives had seven (7) calendar days to rescind the agreement.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 12/18/23, the facility did not ensure the resident's right to personal privacy during medical treatments for one (Resident #62) of one resident reviewed. Specifically, the Podiatrist completed Resident #62's exam and treatment in a common area in the presence of other residents. The finding is: The policy and procedure titled Residents' Rights revised 11/2014 documented the facility respects residents' rights in providing care. All residents are afforded their right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and personal care for personal needs and communications with and access to persons and services inside and outside of the facility. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00324906) completed during the Standard survey on 12/18/23, the facility did not ensure the resident's right to be free from verbal abuse and neglect for one (Resident #134) of four residents reviewed. Specifically, on 9/26/23 Resident #134 reported Certified Nursing Assistant #11 yelled, swore at them, took their call light away and threw it at the wall. The finding is: The policy and procedure titled Resident Abuse: Investigation and Reporting dated 1/23, documented it is the facility's policy to prohibit and assure the residents' rights to be free from verbal abuse, physical abuse, sexual abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00325623) during the Standard survey completed on 12/18/23, the facility did not ensure that all residents were free from physical restraints for the purpose of discipline or convenience, and that are not required to treat the resident's medical symptoms for one (Resident #113) of one resident reviewed for physical restraints. Specifically, on 10/8/23 a wet floor sign was placed behind the rear wheels of Resident #113's wheelchair to prevent them from moving freely. The finding is: The policy and procedure titled Restraints dated 10/2022 documented the facility creates and maintains an environment that fosters minimal use of restraints. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 12/18/23, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #15) of three residents reviewed. Specifically, Certified Nursing Assistant #8 did not provide/utilize a rolling walker during a transfer per the plan of care and the resident fell. The finding is: The policy and procedure titled Resident Accident and Incident Report and Follow up Investigation revised 6/2022 defined Accident as an unintentional or unexpected occurrence that is undesirable or unfortunate and did result in, or might have resulted in, injury, damage, harm, or loss. The facility could not provide a policy and procedure for care plan implementation. [...]

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey completed 12/18/23, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of communicable diseases and infections for three (Residents #31, #95, and #116) of three residents reviewed for airborne and droplet precautions. Specifically, staff did not wear appropriate personal protective equipment, including gowns, gloves, eye protection and N95 (respirator, not resistant to oil- based aerosols, 95 efficiency) masks prior to entering COVID-19 (Coronavirus Disease 2019) positive resident's rooms. Additionally, Resident #116's door lacked airborne/droplet precaution instructions to put on a N95 mask before entering the room.

Inspectors wroteBased on interview and record review conducted during a Standard survey completed 12/18/23, the facility did not implement an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for one (Resident #131) of two residents reviewed. Specifically, Resident #131 received Macrodantin (an antibiotic) since 5/23/23 for urinary tract infection prophylaxis (prevention) without documented evidence to support its continued use, appropriate indications for continued use, and lack of monitoring and tracking of its use. Additionally, no rationale regarding prophylactic antibiotic use was given by the physician/prescriber on the medication regimen review dated 7/29/23. The finding is: [...]

Inspectors wroteBased on interview and record review during a complaint investigation (Complaint #NY00274853) completed on a Standard survey conducted from 5/23/22 through 5/31/22, the facility did not ensure that all alleged violations including abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin, are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse, to the appropriate official (including the State Survey Agency). Four (Residents #16, 22, 60, and 109) of four residents reviewed for reporting of alleged violations of abuse were involved in incidents not reported timely to the New York State (NYS) Department of Health (DOH) as required. Specifically, resident to resident altercations (#16, 22, 60, and 109) and injury of unknown origin (#60).