Greenfield Skilled Nursing and Rehabilitation

Inspectors wroteBased on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure the Interdisciplinary Team (IDT) determined whether the self-administration of a topical medication was clinically appropriate. This affected one (Resident #09) of one resident reviewed for self-administration. The facility census was 39 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop a plan of care for residents with a gastrostomy tube and receiving tube feedings. This affected one (Resident #07) of two residents reviewed for enteral tube feeding care plans. The facility census was 39. Findings Included:Review of the medical record revealed Resident #07 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, diabetes mellitus type II, chronic obstructive pulmonary disease, depression, atherosclerosis, protein-calorie malnutrition, morbid obesity, hyperlipidemia, chronic pain, sciatica, asthma, cerebral infarction, anxiety, depression, and epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #07 had minimally impaired cognition. [...]

Inspectors wroteBased on medical record review, interviews, facility policy review, review of job descriptions, and review of information from the Ohio Board of Nursing, the facility failed to ensure pressure ulcer interventions were implemented timely and weekly assessments, including staging, were completed per the professional standards of practice for Resident #28. This affected one (Resident #28) out of six residents reviewed for pressure ulcer care. The facility census was 39. Findings Included:Review of the medical record for Resident #28, revealed an admission date of 03/11/25. Diagnoses included cerebral infarction due to embolism of right middle cerebral artery, heart failure, neuromuscular dysfunction of bladder, weakness and muscle weakness and multiple sclerosis. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to accurately transcribe, clarify and follow a prescriber's order for a resident who was on a voiding trial after removal of a Foley catheter. This affected one (Resident #06) of five residents with indwelling urinary catheters. The facility census was 39 residents.

Inspectors wroteBased on record reviews, review of resident fund account documentation, review of self reported incident, staff interviews, and facility policy review, the facility failed to ensure appropriate handling of resident funds. This affected four Residents (#6, #24, #42, #46) of four reviewed for resident funds. Facility identified 19 Residents (#2, #3, #6, #7, #8, #15, #19, #21, #24, #25, #26, #29, #37, #42, #43, #44, #45, #46, #47) potentially affected by the accounting practice. Facility census was 41.

Inspectors wroteBased on record review, self-reported incident (SRI) review, review of the facility investigation, resident interview, staff interview, and policy review, the facility failed to ensure a thorough investigation was completed for Resident #51 who had an allegation of abuse and for Residents #7, #42, and #46 who were involved with an allegation of misappropriation. This affected four residents (#7, #42, #46, and #51) out of four reviewed for abuse, neglect, and misappropriation. The facility identified 19 residents (#2, #3, #6, #7, #8, #15, #19, #21, #24, #25, #26, #29, #37, #42, #43, #44, #45, #46, #47) who were potentially affected by the accounting practices related to the misappropriation SRI #261495 and one resident (#51) identified in the abuse SRI #262018. The facility census was 41. Findings Include: 1. [...]

Inspectors wroteBased on record reviews, review of resident fund account documentation, review of self reported incident investigation, staff interviews, and policy review, facility failed to ensure residents were free from the potential of misappropriation. This affected three Residents (#7 #42 and #46) of three reviewed for misappropriation. Facility census was 41.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a safe discharge plan was implemented. This affected one resident (#48) of three reviewed for discharge planning. The facility census was 41. Findings Include: Review of the medical record for Resident #48 revealed an admission date of 02/19/25 and a discharge date of 05/22/25. Diagnoses included pulmonary disease, respiratory failure, embolism of thoracic aorta, cerebral infarct, bipolar disorder, schizophreniform disorder, skin picking disorder and neuropathy. Review of the plan of care dated 03/05/25 revealed Resident #48 would possibly require discharge planning with interventions to provide information on community resources and utilize resources (for example: home health care) and participate in therapy. [...]

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure food was stored and served in a safe and sanitary manner to prevent foodborne illness. This affected all 42 residents who received food from the facility kitchen. The facility census was 42.

Inspectors wroteBased on observation, staff interview, review of a facility provided resident list, and review of a menu spreadsheet, the facility failed to ensure residents received food portions based on the menu spreadsheet. This affected 17 (#02, #04, #05, #06, #07, #09, #11, #12, #13, #14, #23, #30, #32, #33, #36, #38 and #40) of 17 residents that received mechanical soft or pureed diets in a facility census of 42.

Inspectors wroteBased on observation, staff interview, medical record review, review of a meal spreadsheet, and policy review, the facility failed to serve food as prescribed for residents on a controlled carbohydrate therapeutic diet. This affected 15 (#8, #3, #28, #33, #25, #37, #7, #32, #16, #2, #29, #147, #145, #148, and #18) of 15 residents who received a controlled carbohydrate diet. The facility total census was 42. Findings Included: Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included anxiety, somnolence, migraines, fibromyalgia, encephalopathy, diabetes, anxiety disorder, history of cellulitis of limb, morbid obesity, irritable bowel, cognitive impairment, chronic kidney disease, chronic pain, and psychosis. [...]

Inspectors wroteBased on observation, resident and staff interview, medical record review, manufacturer user manual review, review of the Long-Term Care Facility Resident Assessment Instrument 3.0 user's manual, and review of a government website, the facility failed to accurately code the status of a non-invasive mechanical ventilation on resident Minimum Data Set (MDS) assessments. This affected one (#24) of one residents reviewed for ventilators. The facility census was 42.

Inspectors wroteBased on staff interview and medical record review, the facility failed to to ensure resident Preadmission Screening and Resident Review (PASARR) documents were accurate regarding a resident's current conditions and diagnoses. This affected one (#15) of two residents reviewed for PASARR documents. The census was 42.

Inspectors wroteBased on medical record review and staff interview, the facility failed to notify the state mental health authority with a significant change Preadmission Screening and Resident Review (PASARR) for a resident with a change in their mental health condition. This affected one (#02) of two residents reviewed for PASARR documents. The facility census was 42.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a new pre-admission screening and resident review (PASARR) following an addition of a residents's new psychiatric diagnosis. This affected one (Resident #8) of three residents reviewed for PASARR. The facility census was 42.