Greenfield Rehab and Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Apr 14, 2022

  This citation pertains to intake #MI 315 and MI 246 Based on interview and record review, the facility failed to ensure 18 residents (R901, R905, R909, R910, R911, R915, R916, R917, R918, R919, R920, R921, R922, R923, R924, R925, R926 and R927) of 18 residents reviewed for abuse/neglect, were provided an environment free of neglect, resulting in an immediate jeopardy (IJ) when Nurse A failed to ensure Nursing supervision was provided and medication/treatments were administered during the afternoon shift (3:00 PM.-1:00 PM.) on 3/22/22 for the 18 residents residing on the unit, increasing the likelihood for serious injury and/or death. Findings include: The IJ began on 3/22/22. The IJ was identified on 4/13/22. […]

• Immediate jeopardy, isolatedF600Jul 25, 2025

  Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for one (R93) of two residents reviewed for death by neglecting to adequately assess/monitor a resident with an identified change in condition, timely notify the physician of resident's status and timely transfer the resident to a higher level of care, resulting in a delay in identifying and treating the resident with a history of respiratory distress leading to death in the facility. The deficient practice resulted in the increased likelihood of serious harm, serious injury and /or death to occur. […]

• Immediate jeopardy, isolatedF689Jun 1, 2023

  This citation pertains to intake #MI00136875 Based on interview and record review the facility failed to prevent the elopement of one resident (R901) of two residents reviewed for elopement, resulting in immediate jeopardy (IJ) when R#901 who was previously identified as an elopement risk and had severe cognitive impairment, exited the building and left the facility premises without staff supervision increasing the likelihood of serious injury, serious harm, serious impairment, or death. Findings include: On [DATE], a facility reported incident that was submitted to the State Agency was reviewed and indicated that R901 had eloped from the facility grounds without the knowledge of the facility staff on [DATE]. […]

• Immediate jeopardy, isolatedF689Dec 8, 2022

  This citation pertains to Intake Number(s): MI00133024 and MI00133027. Based on observation, interview, and record review, the facility failed to implement effective interventions to prevent elopements for one (R707) of three residents reviewed for elopement, resulting in an Immediate Jeopardy (IJ) when R707, who had severely impaired cognition, a history of eloping through the second story window, and known exit seeking behaviors, eloped through the second story window of their room for the third time, was found a quarter mile away, bleeding from the mouth and arm, in approximately 32 degrees Fahrenheit weather, in the dark, near a highly trafficked road. R707 was taken to the hospital where it was identified that he sustained vertebral (spine) body compression fractures. […]

• Actual harm, isolatedF689Aug 12, 2026

  Based on observation, interview and record review, the facility failed to ensure a resident was positioned safely during provision of care and ensure fall interventions were maintained for two (R30 and R15) of nine residents reviewed for accidents, resulting in R30 sustaining a closed fracture of proximal end of right humerus; and the facility failed to ensure an environment free from accident hazards for three (R2, R32, and R45) of nine residents reviewed for accidents. Findings include:R30: On 8/10/26 at 10:10 AM, during an interview with R30's roommate, the roommate reported a concern that R30 had fallen out of bed about a month ago when the nursing assistant was providing care and R30 fractured their collar bone. […]