Greenfield Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 7, 2023

  Based on interview and record review, the facility failed to ensure a plan of care was followed related to a resident's transfer status to where a resident (Resident M) was transferred with one person, without the utilization of a gait belt, and later identified with a subluxation to the right shoulder for 1 of 3 residents reviewed for accidents. The deficient practice was corrected by 6/2/23, prior to the start of the survey, and was therefore past noncompliance. The facility had completed assessments, education related to transfers and gait belt utilization, and audits related to transfers. […]

• Actual harm, isolatedF600Feb 13, 2023

  Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse perpetrated by another resident, resulting in a fall and subsequent hip fracture, requiring a hospitalization , for 1 of 5 residents reviewed for abuse. (Residents S and T) Findings include: The Executive Director (ED) provided a copy of a state reportable incident report on, 2-10-23 at 10:45 a.m., dated 2-7-23, which indicated on 2-7-23 at 3:01 p.m., Resident T entered the room of Resident S while holding a folding chair and attempted to hit [name of Resident S]. […]

• Actual harm, isolatedF689Jul 26, 2022

  Based on interview, observations, and record review, the facility failed to provide adequate supervision for Resident 44 while in a Broda (tilt-in-space positioning chair) chair resulting in a fall with a major injury of multiple broken ribs, failed to provide a fall intervention of a colored call light for Resident 48 , failed to provide supervision for Resident 118 and 119 during smoking activities, and failed to update an elopement risk assessment for Resident 520 for 5 out of 6 residents reviewed for accidents and hazards. Findings include: 1. The clinical record for Resident 44 was reviewed on 7/19/22 at 12:04 p.m. Resident 44's diagnoses included, but not limited to, dementia with behavioral disturbance, anxiety disorder, and closed fracture of left femur neck with routine healing. […]

• No harm, potential for more than minimal, widespreadF812Sep 13, 2023

  Based on observation and interview, the facility failed to ensure that food was dated, out of date food was removed, and a storage scoop was not stored inside of a container with food. This had the affect 112 of 115 residents who resided in the facility. Findings include: A dietary observation, dated 9/6/2023 at 10:48 a.m., indicated in the dry food storage there was a large storage container with no date on the container, a container of cane sugar dated 1/5/2021, white rice in a container dated for 4/3/2021, flour in a container without a date, a box with an open plastic bag contained tea leaves without a date on it, and a portioning scoop was found inside of the brown sugar. […]

• No harm, potential for more than minimal, widespreadF812Jun 28, 2022

  Based on observation and interview, the facility failed to serve food in accordance with professional standards for food service safety by placing unwrapped bread rolls directly on food trays with bare hands, having the maintenance manager while in the kitchen, with his surgical mask pulled down below his chin leaving his nose and mouth exposed and licking his fingers to separate meal tickets then touching tops of lunch trays and milk cartons; having fruit cups, cottage cheese cups, dinner rolls and pre-poured drinks left open to air in a high traffic area when delivered to resident rooms; and not ensuring proper hot holding temperatures were maintained for 123 residents who reside at the facility. Findings include: 1. […]