Greenfield Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Greenfield Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jan 3, 2023

  Based on record review and interviews conducted during a Partial Extended Abbreviated survey(Complaint #NY00307854), the facility failed to initiate Cardiopulmonary Resuscitation (CPR) to a resident who had Full code status with advance directives in place for one (Resident #1) of four residents reviewed. Specifically, on [DATE] Resident #1, whose advance directives status was a Full code, had a change of condition at 2:45 AM. The Licensed Practical Nurse (LPN) Team Leader #2 correctly identified Resident #1 as a full code and notified the LPN Supervisor #1. LPN Supervisor #1 relayed the change of condition to the Registered Nurse Supervisor (RNS #1). […]

• No harm, potential for more than minimal, isolatedF609Feb 25, 2026

  Based 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. […]

• No harm, potential for more than minimal, isolatedF605Aug 8, 2025

  Based 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. The findings are: The policy titled Medication Regimen Review revised 9/2017 documented the consultant pharmacist will perform a drug regimen review on each resident residing at the facility for the objective to try to minimize or prevent adverse consequences or to prevent resident from receiving unnecessary drugs. […]

• No harm, potential for more than minimal, isolatedF690Aug 8, 2025

  Based 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. […]

• No harm, potential for more than minimal, isolatedF694Aug 8, 2025

  Based 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). […]