Greenfield Rehabilitation & Health Care Center

Inspectors wroteBased on record review, staff and family interviews, and facility policy review the facility failed to obtain all of 1 of 3 resident's (Resident #1) medications once they were admitted to the facility. The facility reported a census of 42 residents.

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review the facility failed to provided incontinent cares on the overnight shift for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 42 residents.

Inspectors wroteNumber of residents sampled: 3Number of residents cited: 1Based on clinical record review, family interview, staff interviews, hospital record review and policy review, the facility failed to properly supervise a resident and failed to implement interventions to prevent a fall for 1 of 3 residents reviewed. Resident #49 sustained a femur fracture after she fell from the commode. The facility reported a census of 43 residents.

Inspectors wroteNumber of residents sampled: 11Number of residents cited: 8Based on clinical record review, staff interview and guidance from the 2024 Resident Assessment Instrument (RAI) Manual, the facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments within federal guidelines for 6 of 11 residents (#1, #2, #4, #6, #8, #18) reviewed for MDS Assessments. The facility reported a census of 43 residents.

Inspectors wroteNumber of residents sampled: 3Number of residents cited: 1Based on staff interviews, Electronic Health Record (EHR) review, policy review and document review, the facility failed to provide the estimated cost of service with the end of a Medicare part A stay or when all of part B therapies were ending to 1 of 3 resident representatives (Resident #6). The facility reported a census of 43 residents.

Inspectors wroteNumber of residents sampled: 3Number of residents cited: 1Based on clinical record review, staff interview and guidance from the 2024 Resident Assessment Instrument (RAI) Manual, the facility failed to complete Quarterly Minimum Data Set (MDS) Assessments within federal guidelines for 1 of 3 (Resident #39) residents reviewed. The facility reported a census of 43 residents.

Inspectors wroteNumber of residents sampled: 13Number of residents cited: 2Based on clinical record review, staff interviews, information from a drug manufacturer and guidance from the 2024 Resident Assessment Instrument (RAI) Manual, the facility failed to accurately reflect the status of 2 of 13 residents in the Minimum Data Set (MDS) Assessments (Resident #2, Resident #6). The facility reported a census of 43 residents.

Inspectors wroteNumber of residents sampled: 13Number of residents cited: 1Based on clinical record review and staff interviews, the facility failed to implement a Baseline Care Plan within 48 hours of admission for 1 of 13 residents reviewed (Resident #2). The facility reported a census of 43 residents.

Inspectors wroteNumber of residents sampled: 3Number of residents cited: 3Based on observations, clinical record review, staff interviews, and policy review, the facility failed to prevent indwelling catheters from potential contamination by securing the urine drainage bag on a resident's trash can and allowing a drainage bag on rest on the floor for 2 of 3 residents reviewed (#3, #22). Staff also failed to don Personal Protective Equipment (PPE) or perform proper hand hygiene during indwelling catheter care for 1 of 3 residents reviewed (#29). The facility reported a census of 43. 1. On 7/14/2025 at 12:24 PM, Resident #22 was observed seated at a dining room table with an indwelling urinary catheter. At 2:21 PM, Resident #22’s urinary bag was observed hanging on the side of the trashcan to the right of his recliner. [...]

Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to establish comprehensive, resident specific care plans for 4 of 4 residents reviewed (Resident #9, #13, #4 and #26). The facility reported a census of 29 residents.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to ensure that opened food items were dated. They failed to mitigate possible food contamination by using proper hand hygiene and hair net use. The facility reported a census of 29 residents.

Inspectors wroteBased on clinical record reviews, observations, resident interview, staff interviews, and policy review, the facility failed to review and revise the care plan to include focus area and interventions for 2 of 15 residents (Resident #7 and Resident #15) reviewed. The facility reported a census of 29 residents.

Inspectors wroteBased on observation, pharmacist interview, staff interview and clinical record review the facility failed to follow physicians' orders for 1 of 4 residents reviewed during medication pass. Resident #128 had a medication order for 100 milligrams (mg) of Sertraline, and the pharmacy sent a bubble pack of pills for 75 mg. Staff did not notice the discrepancy and had administered the wrong dose 26 times. The facility reported a census of 29 residents.

Inspectors wroteBased on clinical record review, observations, resident interview, staff interview, and policy review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 1 residents reviewed, requiring the use of oxygen (Resident #15). The facility reported a census of 29 residents

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review, the facility failed to document the correct medication provided for 1 of 6 (Resident #26) residents reviewed. The facility reported a census of 29 residents

Inspectors wroteBased on clinical record review, observations, staff interviews, and policy reviews, the facility failed to provide adequate hand hygiene and Enhanced Barrier Precautions (EBP) for 1 of 2 (Resident #23) residents reviewed. The facility reported a census of 29 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to provide timely notification to the physician and family for a significant weight loss for 1 of 1 resident reviewed (Resident #37). The facility reported a census of 43 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to provide routine scheduled baths for 1 of 15 residents reviewed (Resident # 16). The facility reported a census of 43 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and facility policy review the facility failed to provide adequate supervision to mitigate a resident's risk for elopement for 1 of 2 residents reviewed (Resident #40). On 6/9/23 sometime between 7:20 PM and 7:35 PM, Resident #40 exited the building and a staff member found the resident outside the building, approximately 200 feet east of the facility, in grass approximately 3 feet tall. The facility reported a census of 43 residents.

Inspectors wroteBased on facility document review and staff interviews the facility failed to ensure a Registered Nurse (RN) was in the facility for eight (8) consecutive hours for 8 of 92 days reviewed (March, April and May of 2023). The facility reported a census of 43 residents.