Greenfield Care Center of Fillmore, LLC

In the surveyor’s words

From the most serious findings on record at Greenfield Care Center of Fillmore, LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 13, 2024

  Based 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). Findings: During a concurrent observation and interview, on 2/12/24 at 10:03 a.m., inside Resident 1's room, the resident was awake and on bed with the left forearm resting on a pillow. […]

• No harm, potential for more than minimal, patternF656Mar 7, 2025

  Based 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. Findings: 1. During a review of Resident 35's most recent MDS Annual Assessment, Assessment Reference Date (ARD - the end of observation period), dated 12/21/24, section A for language indicated, Resident 35's preferred language is Spanish. […]

• No harm, potential for more than minimal, patternF658Mar 7, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF755Mar 7, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF759Mar 7, 2025

  Based 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. Findings include: This LVN 3 administered medications to sample Resident 29 on 3/6/2025 at 9:00 am, which included Divalproex DR 250 mg tablet. The medication nurse proceeded to crush all of this resident's medications including this resident's Divalproex which had the designation of DR on the label of the bubble pack. […]