Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenfield Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
A resident with hypertension and other comorbidities was admitted with a physician order for doxazosin mesylate BID, but the facility failed to obtain and administer the medication as ordered. The script sent to pharmacy differed from the dose entered on the MAR, the drug was not available in the building or emergency kit, and multiple scheduled doses over several days were not given. Staff documented a code on the MAR directing review of progress notes, yet documentation only reflected that the first missed dose was due to waiting for pharmacy delivery, with no explanation for later missed doses. The resident informed family that medications were not received, and the charge nurse told the family that the day nurse had not followed through with the orders, contrary to the facility’s admission policy requiring immediate-care medication orders.
A resident with paraplegia, ulcerative colitis, and frequent urinary and bowel incontinence, who required substantial/maximal assistance with toileting and personal hygiene, reported that overnight staff often failed to provide incontinent care despite her use of the call light. She stated staff would sometimes ignore the call light or enter, say they would return, turn off the light, and not come back, leaving her wet about once a week. Her care plan required staff to check and change her brief daily and PRN, perform peri care after each incontinent episode, and wash, rinse, and dry the perineum. Two CNAs confirmed the resident’s complaints and reported that overnight staff were not consistent in keeping residents dry or thoroughly cleaning her when bowel movements spread to the front. The Administrator was unaware of these issues, while the DON stated staff were expected to round every two hours for incontinence care per facility policy.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility did not complete and transmit comprehensive MDS assessments within the federally mandated 14-day period for several residents. The DON, who lacks detailed MDS regulatory knowledge, relied on verbal or informal notifications from the MDS Coordinator, an LPN, to sign off on assessments, and the facility had no formal policy guiding the MDS process.
A resident did not have a required Quarterly MDS Assessment completed within the federally mandated timeframe. Review of the EHR showed that after the resident's re-entry, the next quarterly MDS was due but was not scheduled or completed. The MDS Coordinator indicated she was unaware that the quarterly assessment was still required after completing a Medicare 5-day assessment, and the facility lacked a specific policy for MDS Assessments.
Two residents had inaccurate MDS assessments: one did not have therapy minutes properly recorded due to a software issue and lack of verification, while another was incorrectly documented as receiving insulin injections when only a GLP-1 RA medication was administered. These errors were acknowledged by the MDS Coordinator and were not supported by the clinical record or medication administration documentation.
A resident who transferred from Assisted Living to LTC did not have a Baseline Care Plan implemented within 48 hours of admission. The previous care plan from Assisted Living was not closed, and a new LTC-specific plan was not initiated until nearly two weeks later. Staff confirmed the oversight, and the facility's policy lacked clear timelines for care plan completion.
Surveyors observed deficient infection control practices involving indwelling urinary catheters, including drainage bags being placed on a trash can and the floor, and inconsistent use of PPE and hand hygiene by staff during catheter care. Residents affected had significant medical conditions requiring strict adherence to infection prevention protocols, but staff failed to follow care plans and facility policies regarding catheter management and PPE use.
The facility failed to create comprehensive care plans for four residents, leading to deficiencies in addressing their medical needs. A resident with intact cognitive ability was on high-risk medications without a care plan to monitor side effects. Another resident with severe cognitive deficits lacked a care plan addressing medication side effects and dementia symptoms. Two other residents with severe cognitive impairments had care plans that did not specify side effects to monitor. The facility's policy required comprehensive care plans, but this was not followed.
The facility failed to adhere to food safety and hygiene practices, as observed during a survey. A staff member was found with an uncovered beard, and there were undated and uncovered food items in storage. Additionally, a dietary aide used improper glove usage during food preparation. These actions violated the facility's policies on hair restraints, food storage, and glove usage, potentially compromising food safety.
The facility failed to update care plans for two residents, leading to deficiencies. A resident with arthritis and a recent hip replacement was using compression stockings not documented in the care plan. Another resident with Parkinson's and a history of strokes was using oxygen, which was also not documented. Staff interviews confirmed these oversights, contrary to facility policy requiring comprehensive care plans.
A resident with moderate cognitive deficits was prescribed 100 mg of Sertraline, but the pharmacy provided 75 mg doses, which were administered 26 times without staff noticing the error. The discrepancy was discovered during a medication pass when an RN decided to recheck the orders. The facility's records showed the correct order, but the pharmacy was unaware of the change.
A facility failed to provide proper respiratory care for a resident with moderate cognitive impairment and a history of serious health conditions. Despite physician orders for oxygen use, the resident's care plan and records lacked instructions for oxygen tubing changes. Observations showed unmarked tubing near the floor, and staff interviews revealed non-compliance with the facility's policy for weekly tubing changes and documentation.
A resident with severe cognitive impairment and dementia received incorrect medication documentation due to a failure to update the MAR after a telehealth appointment increased the Rivastigmine Patch dosage. Staff interviews revealed unawareness of the discrepancy, and the facility lacked a specific medication administration policy.
A facility failed to ensure proper hand hygiene and Enhanced Barrier Precautions (EBP) during catheter care for a resident with an indwelling catheter. A CNA did not change gloves or perform hand hygiene between tasks and used the same gloves to obtain and apply barrier cream. The DON intervened but no additional PPE was used. The resident had intact cognition and multiple diagnoses, including neurogenic bladder. The facility's infection control policies were not adhered to, and EBP equipment installation was delayed due to a tornado.
Failure to Obtain and Administer Ordered Antihypertensive Medication at Admission
Penalty
Summary
The deficiency involves the facility’s failure to obtain and administer all ordered medications for a newly admitted resident in accordance with professional standards and its own admission policy. A cognitively intact resident with diagnoses including hypertension, hip fracture, stroke, depression, cognitive communication deficit, and atrial fibrillation was admitted with a physician order for doxazosin mesylate 2 mg, 0.5 tablet PO BID. The script sent to the pharmacy reflected this order, but the MAR was entered as doxazosin mesylate 1 mg, 0.5 tablet PO BID, and the medication was not available in the building. On the MAR for several scheduled doses over three days, staff documented the code “6” (see progress notes) instead of administering the medication. Progress notes documented that the medication was not given on the night of admission because staff were waiting for pharmacy delivery, but there was no documentation explaining why subsequent doses on the following days were not given. Blood pressure readings during this period showed varying values, and review of the emergency kit list confirmed that doxazosin was not stocked there. The resident’s family reported that the resident called to say she did not receive her medications on the day of admission or that night, and when the family member spoke with the charge nurse, the nurse stated the day nurse had not followed through with the orders. Staff interviews revealed that the usual admission process includes obtaining prior MARs, securing physician orders, entering them into the computer, and faxing them to the pharmacy, and that if medications are not available, staff may obtain an order to start later or use the emergency kit if immediate administration is needed. The DON stated that if the medication had not been delivered, staff should have initiated calls to obtain it as soon as possible and checked the emergency kit. The ADON/MDS Coordinator later identified that the script sent to the pharmacy did not match the MAR order and noted that staff should have documented in progress notes why the medication was not given. The facility’s admission policy requires that the attending physician provide medication orders needed for the immediate care of the resident prior to or at admission.
Failure to Provide Required Overnight Incontinent Care and ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care and assistance with activities of daily living during the overnight shift for one resident. The resident had a BIMS score of 15/15, indicating no cognitive impairment, and required substantial/maximal assistance with toileting hygiene and personal hygiene due to bilateral upper and lower extremity impairments. The MDS documented that the resident was frequently incontinent of urine and always incontinent of bowel, with diagnoses including ulcerative colitis, paraplegia, anxiety, and depression. The resident’s care plan directed staff to change her disposable brief daily and as needed, check her for incontinence per her request and as required, wash, rinse, and dry the perineum, and provide peri care after each incontinent episode. During interview, the resident reported that on the overnight shift she was not being changed as she should be, stating that when she had a bowel movement and pulled her call light, staff would sometimes let the call light go unanswered or enter the room, state they would return, turn off the call light, and then not come back. She indicated this occurred about once a week and always when she was incontinent of urine, and that staff would not assist her with incontinent cares; she also reported having issues with skin in the affected area and the use of cream to help prevent skin issues. Two CNAs confirmed that the resident had complained to them about overnight staff not cleaning her up after incontinence and described that overnight staff were not very good about ensuring residents were not wet and that not all staff cleaned her properly when bowel movements came up the front. The Administrator stated she was not aware of issues with overnight incontinent care, while the DON stated staff were expected to round every two hours to check and change incontinent residents and offer or remind toileting, consistent with the facility’s ADL policy requiring care according to the individualized care plan.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Complete and Transmit MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments within the federally required timeframe for six out of eleven residents reviewed. According to the 2024 Resident Assessment Instrument (RAI) Manual, the MDS Completion Date must be no later than the 14th calendar day after a resident's admission. In multiple cases, the MDS assessments were completed and signed well beyond this 14-day window, with completion dates ranging from day 16 to day 26 of the residents' stays. The clinical records for these residents showed that the required comprehensive assessments were not finalized in accordance with federal guidelines. Interviews with facility staff revealed that the Director of Nursing (DON), who is responsible for signing the MDS assessments, does not possess detailed knowledge of MDS regulations and relies on the MDS Coordinator, an LPN, to inform her when assessments are ready for signature. The DON stated that she typically signs the assessments on the same day she is notified, but there is no formal policy in place regarding the MDS assessment process. The facility administrator confirmed that there is no written policy and that the facility follows the RAI Manual guidelines.
Failure to Complete Timely Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a required Quarterly Minimum Data Set (MDS) Assessment within the federally mandated timeframe for one resident. Clinical record review showed that after the resident's re-entry, the next quarterly MDS was due but was neither scheduled nor completed, as confirmed by the MDS tracker in the electronic health record. The last assessment completed was a Medicare 5-day MDS, which is a payment assessment and does not fulfill the OBRA assessment schedule requirements. The MDS Coordinator stated she was unaware that the quarterly assessment was still required after completing the 5-day assessment. The facility did not have a policy regarding MDS Assessments and relied on the RAI Manual guidelines.
Inaccurate MDS Assessments Due to Documentation and Data Entry Errors
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two of thirteen sampled residents. For one resident, the MDS assessment did not reflect the actual therapy minutes received during the seven-day lookback period, despite the resident having completed and participated in multiple therapy sessions, as confirmed by both the resident and a therapy minutes report. The MDS Coordinator acknowledged that therapy minutes are typically pulled automatically into the assessment, but due to a recent software change, the data did not transfer as expected. The Coordinator did not verify the therapy minutes with the therapy department, resulting in the omission of therapy services from the resident's MDS. For another resident with a diagnosis of diabetes mellitus, the MDS assessment incorrectly documented that the resident received insulin injections during the lookback period. However, the Medication Administration Record (MAR) did not show any insulin administration for the month. The MDS Coordinator stated she had recorded an insulin injection because the resident was receiving Ozempic, not realizing that Ozempic is not an insulin but a GLP-1 receptor agonist. The facility did not have a specific policy for MDS assessments and relied on the RAI Manual for guidance.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency was identified when a resident transferred from the facility's Assisted Living to the Long Term Care (LTC) section and did not have a Baseline Care Plan implemented within 48 hours of admission, as required. The resident's clinical record showed an admission date to LTC, but the most recent Care Plan was not initiated until 12 days after admission. The earliest documented initiation date for any focus area within the Care Plan was 17 days post-admission. Staff interviews confirmed that no Baseline Care Plan was created upon the resident's transfer to LTC, and the previous Assisted Living Care Plan was not closed or replaced with a new one specific to LTC needs. The Director of Nursing (DON) and the MDS Coordinator both acknowledged the oversight, with the MDS Coordinator stating that she typically initiates key focus areas immediately but was unaware of why this did not occur for this resident. The facility's care planning policy, approved in December 2024, did not specify required timelines for completing baseline or comprehensive care plans. This lack of timely care planning upon admission resulted in the failure to meet the resident's immediate needs as required by regulation.
Deficient Infection Control Practices in Catheter Care
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices related to the management of indwelling urinary catheters. For two residents, staff failed to properly secure urinary drainage bags, with one bag observed hanging from a trash can and another resting on the floor. These actions were contrary to both the residents' care plans and facility policy, which require catheter bags to be kept off the floor and positioned below the level of the bladder. Staff interviews revealed uncertainty about appropriate placement of catheter bags, and some staff admitted to using the trash can as a hanging point due to a lack of alternatives. In another instance, a staff member providing catheter care to a resident did not consistently follow proper hand hygiene protocols during glove changes and failed to don a gown as required by enhanced barrier precautions. The staff member also handled clean and dirty items without appropriate hand hygiene and did not use a dignity cover for the catheter bag. The resident's care plan and posted CDC guidance required the use of gloves and gowns for high-contact care activities, but these were not consistently followed during the observed care. All three residents involved had significant medical histories, including chronic kidney disease, neurogenic bladder, renal insufficiency, and a history of urinary tract infections. Their care plans specified interventions for catheter care, positioning, and infection prevention, but these were not adhered to during the survey observations. Staff and the Director of Nursing confirmed that the observed practices did not meet facility expectations or policy requirements.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to establish comprehensive, resident-specific care plans for four residents, leading to deficiencies in addressing their medical needs. Resident #9, with intact cognitive ability, was taking high-risk medications for conditions such as heart failure, diabetes, and depression. However, her care plan did not include references to these medications or instructions for staff to monitor for specific side effects. Similarly, Resident #13, who had severe cognitive deficits and was dependent on staff for daily activities, was on antipsychotic and opioid medications. His care plan lacked details on managing the side effects of these medications and did not address his dementia symptoms beyond medication administration. Resident #4, with severe cognitive impairment, was on multiple medications, including antipsychotics and antidepressants. The care plan directed staff to monitor for side effects but failed to specify what those side effects were. Resident #26, also with severe cognitive impairment, was receiving medication for anxiety and dementia, but the care plan did not detail the side effects to monitor. The Assistant Director of Nursing acknowledged that certified nursing assistants needed guidance on medication side effects, which should be included in the care plans. The facility's policy required comprehensive care plans to address all relevant care issues, but this was not adhered to in these cases.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, as observed during a survey. On an initial tour of the kitchen, a staff member was found with an uncovered beard, contrary to the facility's policy requiring hair restraints to prevent hair from contacting exposed food. Additionally, the refrigerator contained uncovered drinks and an undated open bag of shredded lettuce, while the dry storage area had an undated open bag of Cheerios. These observations indicate a lack of adherence to the facility's food storage policy, which mandates that all food items be labeled with the name and date by which they should be consumed or discarded. During a lunch service observation, a dietary aide was seen using improper glove usage, handling multiple food items with the same gloved hand without changing gloves or using utensils like tongs, as required by the facility's hand washing and glove usage policy. The dietary manager acknowledged the need for staff education on glove use and hand hygiene to prevent cross-contamination. These deficiencies highlight lapses in the facility's adherence to professional standards for food preparation and hygiene, potentially compromising food safety for the residents.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to review and revise the care plans for two residents, leading to deficiencies in their care. Resident #7, who had a history of arthritis, pain in the right leg and hip, and a recent hip replacement, was observed wearing compression stockings, which were not documented in the care plan. Despite physician orders for compression stockings starting on 8/9/24, the care plan printed on 8/28/24 did not reflect this intervention. Staff interviews confirmed that the care plan should have included information about the use of compression garments for edema management. Similarly, Resident #15, with a history of Parkinson's Disease, transient ischemic attack, cerebral infarction, and COVID-19, was using oxygen, which was not documented in the care plan. Physician orders indicated the use of oxygen as needed to maintain oxygen saturation above 90%, starting on 8/9/24. However, the care plan printed on 8/28/24 did not include information about oxygen use or parameters. Observations confirmed the presence of oxygen equipment in the resident's room, and staff interviews acknowledged the oversight in care plan documentation. The facility's policy required comprehensive care plans to address all relevant care issues, which was not adhered to in these cases.
Medication Administration Error Due to Dosage Discrepancy
Penalty
Summary
The facility failed to follow physician's orders for a resident during medication administration. The resident, who had moderate cognitive deficits and was taking antidepressant and antianxiety medications, was prescribed 100 mg of Sertraline daily. However, the pharmacy provided a bubble pack containing 75 mg doses, which was administered 26 times without the discrepancy being noticed by the staff. This error was discovered during a medication pass when a registered nurse noticed the incorrect dosage and decided to recheck the orders. The facility's records showed that the order for 75 mg of Sertraline had been discontinued and replaced with a 100 mg order. Despite this, the pharmacy was unaware of the change and continued to supply the incorrect dosage. The Director of Nursing acknowledged that the nursing staff should have adhered to the 5 rights of medication administration, which would have prevented the error. The facility's Skills Checklist also required staff to compare medication labels to the Electronic Medication Administration Record, a step that was evidently missed in this case.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for a resident requiring the use of oxygen. The resident, who had a moderate cognitive impairment and a history of Parkinson's Disease, transient ischemic attack, cerebral infarction, and COVID-19, was noted to have physician orders for oxygen use at 1-2 liters as needed to maintain oxygen saturation above 90%. However, the resident's care plan and medication administration record did not reflect the need for oxygen or instructions for changing the oxygen tubing. Observations over several days revealed that the oxygen tubing in the resident's room was unmarked and hanging near the floor, contrary to the facility's policy that required weekly changes and marking of the tubing. Interviews with staff, including registered nurses and the Director of Nursing, indicated a lack of adherence to the policy, as the tubing was not marked or documented on the medication administration record. The facility's policy on oxygen administration did not specify when the tubing should be changed, contributing to the oversight.
Medication Documentation Error for Resident with Dementia
Penalty
Summary
The facility failed to document the correct medication provided for a resident with severe cognitive impairment, as identified in a clinical record review. The resident, who had diagnoses of non-Alzheimer's dementia and anxiety disorder, was receiving antianxiety and dementia medication. The Medication Administration Record (MAR) for August 2024 showed entries for two different dosages of Rivastigmine Patch, 4.6MG/24HR and 9.5MG/24HR, which were both active from 8/22 through 8/27. This discrepancy arose after a telehealth appointment on 8/21/24, where the Advanced Practice Registered Nurse (APRN) increased the Rivastigmine Patch dosage to 9.5MG/24HR due to the progression of the resident's dementia. Staff interviews revealed that the Registered Nurse (RN) was unaware of the two different orders on the MAR, and the Director of Nursing (DON) acknowledged that the old order should have been removed when the new order was implemented. The Assistant Director of Nursing (ADON) confirmed being present during the telehealth appointment and stated that the old order should have been discontinued. The facility lacked a specific policy for medication administration, and the provided document, "Administration of Meds (Oral)," was undated and only instructed staff to document medications administered in the clinical record.
Inadequate Hand Hygiene and EBP During Catheter Care
Penalty
Summary
The facility failed to provide adequate hand hygiene and Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter. During an observation, a Certified Nursing Assistant (CNA) was seen performing catheter and peri care on the resident without changing gloves or performing hand hygiene between tasks. The CNA also used the same gloves to open a drawer and obtain barrier cream, which was then applied to the resident. The Director of Nursing (DON) intervened by providing a clean glove for the barrier cream, but the CNA did not utilize any additional personal protective equipment during the procedure. The resident involved had a Brief Interview for Mental Status (BIMS) score indicating intact cognition and was diagnosed with conditions including benign prostatic hypertension, end-stage renal disease, neurogenic bladder, and senile degeneration of the brain. The facility's policies on infection prevention and control, including hand hygiene and EBP, were not followed during the care of this resident. The Assistant Director of Nursing (ADON)/Infection Preventionist acknowledged familiarity with EBP but noted that equipment for EBP had not been installed due to a tornado delaying the process.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Greenfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Community Care Center | 15 mi | ★★★★★ | 14 | 0 |
| Creston Specialty Care | 16.6 mi | ★★★★★ | 2 | 0 |
| Accura Healthcare Of Creston | 17.5 mi | ★★★★★ | 2 | 0 |
| Caring Acres Nursing And Rehab Center | 18.8 mi | ★★★★★ | 20 | 0 |
| Azria Health Winterset | 22.1 mi | ★★★★★ | 10 | 0 |
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