Greenfield Rehabilitation & Health Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 17, 2025

  Number of residents sampled: 3Number of residents cited: 1Based on clinical record review, family interview, staff interviews, hospital record review and policy review, the facility failed to properly supervise a resident and failed to implement interventions to prevent a fall for 1 of 3 residents reviewed. Resident #49 sustained a femur fracture after she fell from the commode. The facility reported a census of 43 residents. Findings include:According to the Minimum Data Set (MDS), dated [DATE], Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). She was admitted to the facility on [DATE], and totally dependent on staff for hygiene, dressing, and transfers. […]

• No harm, potential for more than minimal, patternF552Aug 27, 2026

  Based on clinical record review, staff interviews, and policy review, the facility failed to fully inform the resident and/or representative of alternative psychotropic medication options by failing to identify target behaviors (TBs) or non-pharmacologic interventions (NPIs) on psychotropic medication (medications that affect a person's mental state, emotions, and behavior) consent forms for 5 of 5 residents (#5, #8, #4, #30, #42). The facility reported a census of 43 residents. Findings include:1.Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 04 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia with other behavioral disturbances, and depression. […]

• No harm, potential for more than minimal, patternF605Aug 27, 2026

  Based on clinical record reviews, staff interview, and policy review, the facility failed to consistently monitor target behaviors (TBs) or document attempted non-pharmacologic interventions (NPIs) for 5 of 5 residents (#5, #8, #4, #30, #42) who received psychotropic medications (medications that affect a person's mental state, emotions, and behavior). The facility reported a census of 43 residents. Findings include:1.Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 04 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia with other behavioral disturbances, and depression. […]

• No harm, potential for more than minimal, patternF656Aug 27, 2026

  Based on clinical record reviews, staff interview, and policy review, the facility failed to develop a personalized Care Plan that included resident specific target behaviors (TBs) or non-pharmacological interventions (NPIs) for 5 of 5 residents (#5, #8, #4, #30, #42) who received psychotropic medications (medications that affect a person's mental state, emotions, and behavior). The facility also failed to develop a personalized Care Plan that included the use of insulin and diuretics. The facility reported a census of 43 residents. Findings include:1.Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 04 out of 15 which indicated severely impaired cognition. […]

• No harm, potential for more than minimal, patternF761Aug 27, 2026

  Based on observations, staff interviews, and facility document review, the facility failed to secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 43 residents. Findings included:On 8/24/26 at 11:35 AM, a medication cart was observed unlocked with Staff A, Licensed Practical Nurse (LPN) on the other side of the nurses' station with her back to cart area and a pillar blocking her direct line-of-sight to the medication cart. The medication cart contained blood thinners (Eliquis) and antidepressants (trazodone). […]