Greenfield Skilled Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Jul 19, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of a facility self-reported incident (SRI), review of an emergency medical services (EMS) report, review of a 911 call and dispatch log, interviews with facility staff, Physician #31, Physician #35, Emergency Medical Services (EMS) Chief #86, Paramedic #87, facility policy and procedure review and review of the American Red Cross Basic Life Support manual, the facility failed to initiate effective cardiopulmonary resuscitation (CPR) and immediately contact emergency medical services (EMS) for Resident #201. This resulted in Immediate Jeopardy on [DATE] at 2:50 A.M. […]

• Immediate jeopardy, isolatedF689Aug 24, 2021

  Based on observations, medical record review, staff interviews, review of a police report, review of the facilities Self-Reported Incidents (SRI's), interview with a police officer, interview with community member, review of video footage, and facility policy review, the facility failed to provide adequate supervision to prevent the elopement of a resident, without staff knowledge, who was cognitively impaired and assessed as being at risk for elopement. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on [DATE] when Resident #100 eloped from the facility and the resident was found by police 1.5 miles away from the facility on a road that had a 55 Miles Per Hour (MPH) speed limit. […]

• No harm, potential for more than minimal, widespreadF812Dec 5, 2024

  Based on observation, staff interview and policy review, the facility failed to ensure food was stored and served in a safe and sanitary manner to prevent foodborne illness. This affected all 42 residents who received food from the facility kitchen. The facility census was 42. Findings include: 1. Observation of the milk cooler in the kitchen on 12/02/24 at 9:26 A.M. revealed there were two gallons of milk that were opened with an expiration date of 11/30/24. Interview on 12/02/24 at 9:26 A.M. with [NAME] #27 verified there were two gallons of open milk with an expiration date of 11/30/24 in the milk cooler in the kitchen. […]

• No harm, potential for more than minimal, patternF568Aug 20, 2025

  Based on record reviews, review of resident fund account documentation, review of self reported incident, staff interviews, and facility policy review, the facility failed to ensure appropriate handling of resident funds. This affected four Residents (#6, #24, #42, #46) of four reviewed for resident funds. Facility identified 19 Residents (#2, #3, #6, #7, #8, #15, #19, #21, #24, #25, #26, #29, #37, #42, #43, #44, #45, #46, #47) potentially affected by the accounting practice. Facility census was 41. Findings include 1.Review of the medical record for Resident #42 revealed an admission date of 02/21/21 and discharge date of 08/06/25. […]

• No harm, potential for more than minimal, patternF610Aug 20, 2025

  Based on record review, self-reported incident (SRI) review, review of the facility investigation, resident interview, staff interview, and policy review, the facility failed to ensure a thorough investigation was completed for Resident #51 who had an allegation of abuse and for Residents #7, #42, and #46 who were involved with an allegation of misappropriation. This affected four residents (#7, #42, #46, and #51) out of four reviewed for abuse, neglect, and misappropriation. The facility identified 19 residents (#2, #3, #6, #7, #8, #15, #19, #21, #24, #25, #26, #29, #37, #42, #43, #44, #45, #46, #47) who were potentially affected by the accounting practices related to the misappropriation SRI #261495 and one resident (#51) identified in the abuse SRI #262018. […]