Greenfield Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Greenfield Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 27, 2026

  Based on review of facility policy, review of clinical and facility records, review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2025 (RAI-assessment guide used to plan the provision of care for residents), and resident and staff interviews, it was determined that the facility failed to ensure Resident R6 was free of neglect during care, which resulted in actual harm of a laceration to the left posterior head, fracture of left pubic bone with a two part fracture that extended into the pubic symphysis (the front and lower part of left hip bone which separated and fractured), left scapholunate ligament tear (a wrist injury involving bones of wrist that separate due to a tear in the connecting ligament), and shock (a life-threatening medical emergency caused… […]

• Actual harm, isolatedF689Jan 27, 2026

  Based on review of facility policy, review of facility documentation and clinical records, review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2025 (RAI-assessment guide used to plan the provision of care for residents), and resident and staff interviews, it was determined that the facility failed to ensure essential resident safety measures were followed to prevent a fall for one of 17 residents (Resident R6), which resulted in actual harm of a laceration to the left posterior head, fracture of left pubic bone with a two part fracture that extended into the pubic symphysis (the front and lower part of left hip bone which separated and fractured), left scapholunate ligament tear (a wrist injury involving bones of wrist that separate due to a tear in the… […]

• Actual harm, isolatedF686May 21, 2021

  Based on a review of clinical records, facility documentation, facility policy, hospital records, and staff interviews, it was determined that the facility failed to adequately assess, monitor and implement interventions to promote wound healing that resulted in actual harm of worsening pressure ulcers for one of 18 residents reviewed (Resident R61). Findings include: The facility policy, Pressure Injury/Skin Breakdown - Clinical Protocol, dated 1/28/21, revealed that the physician will write orders and identify medical interventions related to wound management. Resident R61's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF947Feb 4, 2025

  Based on review of facility employee in-service training records and staff interview, it was determined that the facility failed to assure that staff completed all the required mandatory trainings for the yearly Nurse Aide (NA) 12-hour mandatory trainings. Findings include: Review of requested records or evidence of in-service mandatory training for all NA's from 1/2024 through 1/2025 was incomplete upon review. The facility was unable to provide complete evidence of completed competencies the the past year. During an interview on 1/31/25, at 2:30 p.m. the Nursing Home Administrator confirmed that no evidence could be provided of NA's 12-hour mandatory in-service trainings as required. 28 Pa. Code 211.12(d)(3)(5) Nursing services 28 Pa. Code 201.18(e)(1) Management 28 Pa. […]

• No harm, potential for more than minimal, widespreadF908Feb 2, 2024

  Based on observations, review of facility records and staff interviews, it was determined that the facility failed to maintain kitchen equipment (one of two food steamers, and one of one walk-in coolers) in safe, operating condition. Findings include: A facility policy entitled Equipment-Facility Repair/Maintenance Needs dated 9/14/23, indicated that the facility will ensure timely attention to any facility equipment or items that require attention, repair, or replacement. Observations on 1/30/24, 11:20 a.m. […]