Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Healthcare Center during CMS and state inspections, most recent first.
Missed Scheduled Showers and Lack of Bathing Documentation: A resident with weakness, depression, nicotine dependence, and impaired mobility did not receive showers as scheduled. The resident reported going weeks without a shower, while staff only cleaned him during bed changes; his hair was greasy and tangled and he had a strong body odor. The EHR showed one shower documented, but no bathing or refusals were recorded for the following days, and an LPN said she had not received documentation showing missed care.
Failure to timely ensure vision services were provided for two residents. One resident with photophobia, anxiety, dementia, and macular degeneration had a care plan for eye care consultation, but family reported repeated requests to the MCUM and prior unit manager without an appointment being scheduled, and the record had no eye consult notes. Another resident with Bell’s Palsy, a cerebral aneurysm, and anxiety reported painful eye symptoms and had an order for optometry consult, but had not been seen by the eye doctor since 2022; the DDR also stated the facility had no policy for ancillary services.
Failure to ensure urology follow-up for a resident with an indwelling Foley catheter. The resident had spina bifida, obstructive and reflux uropathy, frequent catheter leaking, thick sediment, and bladder spasms, with the catheter observed to contain sediment and urine. A urology consult was ordered for repeated leaking, but the record showed no timely follow-up documentation, and the DON stated the unit manager was responsible for tracking consults.
A resident with vascular dementia, adult failure to thrive, and malnutrition requested a spaghetti substitute after declining lunch salad, but staff told her the facility did not have it. The resident’s preferences included salads and other foods such as eggs, fish, and chocolate milk, and the care plan called for offering substitutions if a meal was declined. A CNA confirmed the request was made, while the dietary manager later stated spaghetti and sauce were available and would have been provided if the request had been communicated.
The facility failed to accurately transcribe an admission methadone order and did not have the medication available for a resident with chronic pain, resulting in missed scheduled doses. It also failed to address pain for another resident after an unwitnessed fall with rib injuries; the resident reported a pain level of 5, but the record did not show that PRN pain meds or non-pharmacological interventions were provided, and later hospital records confirmed multiple rib fractures.
The facility failed to provide weekend activities for residents on the Reflections 1 Unit, affecting all 19 residents. A resident with dementia and another who is cognitively intact expressed dissatisfaction with the lack of activities, noting that only monthly church services were offered on weekends. The activity calendar showed minimal weekend activities, and staff confirmed that activity packets were not consistently distributed. The facility was aware of the issue and working to hire staff for weekend activities.
The facility failed to include two residents and their representatives in care plan conferences. A resident with heart failure was not invited to meetings corresponding with his MDS assessments, and there was no evidence of his participation. Another resident with severe cognitive impairment also lacked documented care plan meetings, and their family member reported not being invited. The absence of proper documentation and signatures indicates a failure to adhere to the facility's policy of encouraging participation.
A facility failed to maintain proper catheter care for a resident with obstructive uropathy, as the urinary catheter drainage bag was observed on the floor on two occasions. The resident relies on staff for toileting and transferring. A CNA confirmed that catheter bags should not touch the ground, aligning with the facility's policy.
A resident's hydrocodone-acetaminophen medication was misappropriated by an RN, who admitted to taking extra tablets for personal use. The discrepancies were discovered by a QMA and reported to the Director of Nursing. Despite the misappropriation, the resident did not miss any doses of their prescribed medication.
A resident did not receive prescribed medications upon admission, despite their availability in the facility's Emergency Drug Kit (EDK). The resident, with multiple serious health conditions, was not administered medications such as tamsulosin, mirtazapine, and others. The Regional Director confirmed the medications were available, and the floor nurse was responsible for their administration, as per the facility's policy for emergency pharmacy services.
Missed Scheduled Showers and Lack of Bathing Documentation
Penalty
Summary
The facility failed to provide showers as scheduled for a resident who was cognitively intact and used a wheelchair for ambulation. The resident’s diagnoses included weakness, depression, and nicotine dependence. The admission MDS dated 12/18/25 indicated the resident required substantial to maximal assistance with ADLs and needed 2 or more helpers for shower transfers. During observations and interviews on 1/6/25, 1/7/26, and 1/8/25, the resident stated he had not had a shower for weeks, that staff had only been cleaning him up when changing him in bed, and that no one had come in to offer him a shower. His hair was observed to be shoulder length, greasy, and tangled, and he had a strong sweaty body odor. The EHR showed a shower documented on 12/31/25, but no showers or other bathing were documented from 1/1/26 through 1/8/25, and there were no refusals documented. The care plan dated 9/26/24 identified an ADL deficit related to weakness and impaired mobility and included interventions for substantial to maximal assistance with shower transfers. An LPN stated she did not know why the resident had not had a shower in over 7 days and indicated she had not received documentation showing a refusal or missed care. The facility policy provided stated routine care included bathing and documenting all aspects of care.
Failure to Arrange Timely Vision Services
Penalty
Summary
The facility failed to timely ensure vision services were provided for 2 of 2 residents reviewed for vision and hearing services. Resident H had diagnoses including photophobia, anxiety, and dementia, and her impaired visual function care plan, initiated in July 2025, included arranging consultation with an eye care practitioner as needed. Her family member stated Resident H had macular degeneration and needed to be seen by the eye doctor, and that the Memory Care Unit Manager and a previous unit manager had been informed over the prior months, but no appointment was scheduled. The clinical record contained no progress notes or eye consultation notes showing that she was seen by the eye doctor or that an appointment had been arranged. Resident B had diagnoses including Bell’s Palsy, a cerebral aneurysm, and anxiety, and the annual MDS indicated the resident was cognitively intact. Resident B stated they needed to be seen by the eye doctor because their eyes were always bothering them, it felt like something was in their eyes, they blinked a lot, and it was very painful, and they had notified the NP. The record included a physician order allowing optometry consultation and a care plan noting impaired visual function related to Bell’s Palsy and dry eyes, but the DDR stated Resident B had not been seen by the eye doctor since 2022. The DDR also stated the facility did not have a policy regarding ancillary services.
Failure to Ensure Urology Follow-Up for Resident with Foley Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling Foley catheter was seen by urology after a consult was ordered for repeated catheter leaking and bladder spasms. The resident had diagnoses including spina bifida and obstructive and reflux uropathy, was cognitively intact, and was always incontinent of urine. During observation, the resident stated the catheter always had a lot of sediment, leaked frequently because it clogged with thick sediment and bladder spasms, and caused complete bed changes two to three times a week. The catheter tubing was observed with pale yellow urine and thick sediment. The record showed a plan of care for an indwelling catheter related to obstructive uropathy and bladder spasms. A telehealth note documented the resident had multiple episodes of catheter leaking with bladder spasms and that a urology consult was placed. A physician order also directed a urology consult, and a later progress note stated the resident was being sent for a urology consult. However, the electronic record showed no follow-up documentation until 1/6/26, when a nurse note indicated urology was phoned for the consult. The DDR stated the initial referral and face sheet were faxed and urology was called, but they never returned the call, and there was no documentation in the EHR until the appointment was made again and followed up on. The DON stated the unit manager was responsible for following up on consults.
Failure to Provide Requested Meal Substitute
Penalty
Summary
The facility failed to provide a substitute at lunch when a resident requested one, despite the resident’s documented food preferences and need for increased nutrition. Resident 70 had diagnoses including vascular dementia, cerebral vascular disease, major depression disorder, adult failure to thrive, and hypertension. The resident’s food preference assessment indicated a preference for salads and other foods including fruit, chocolate milk, eggs, cheese, potatoes, fish, grilled cheese, and peanut butter and jelly sandwiches. The registered dietician documented that the resident had a BMI of 15.9, was underweight, malnourished, and needed increased nutrition to promote weight gain. The care plan included offering substitutions if a meal was declined, and the resident’s physician orders included a lacto-ovo vegetarian, dysphagia advanced diet with thin liquids. During lunch, the resident did not eat the salad and told staff she wanted spaghetti with sauce instead. The resident stated she asked staff for the substitute and was told the facility did not have it. A CNA confirmed the resident requested spaghetti with pasta sauce and was told it was not available, and the resident only drank chocolate milk for lunch. The dietary manager later stated she was not aware of the request, verified dietary staff had not been told to provide spaghetti and sauce, and said the facility did have spaghetti and sauce available and would have made it if they had known after the main meal was completed. The regional director of clinical operations stated the facility did not have a policy for food substitutions, but there were several substitutions available daily.
Pain Management Failures for Two Residents
Penalty
Summary
The facility failed to accurately transcribe an admission pain medication order for a resident with chronic pain and respiratory failure, and failed to have methadone available as ordered. The resident’s discharge orders used for admission indicated methadone three times daily routinely, but the medication administration record initially reflected methadone three times daily as needed for pain, with no routine order entered on admission. A physician order the next day clarified methadone three times daily as ordered. The December 2025 MAR showed 15 scheduled doses were not given because the medication was unavailable or the entry was left blank. Staff stated the facility had ongoing issues obtaining methadone and similar medications, and the on-call provider was notified after the medication was unavailable. The facility also failed to address pain for a resident with dementia and rib injuries after an unwitnessed fall. The resident’s pain care plan called for non-pharmacological interventions and medication per orders with evaluation of effectiveness. After the fall, the post-fall evaluation documented right-sided back pain described as a 5 out of 10, aching and heavy, but did not indicate how that pain level was addressed. The resident had standing acetaminophen orders, including scheduled dosing and an as-needed order, but the record showed only the scheduled morning dose was given and no as-needed pain medication was administered. The neurological assessments completed after the fall did not reference pain levels, and the nurse’s note documented back pain and pain with breathing but did not show that any as-needed pain medication or non-pharmacological intervention was provided. The resident was later sent to the emergency room at the family’s request, where she reported right rib and abdominal pain worsened by breathing. Hospital records showed rib contusions and fractures of ribs 8, 9, and 10. Management later stated there was no verification that the resident’s pain level of 5 had been addressed.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide weekend activities for residents on the Reflections 1 Unit, which affected all 19 residents on the unit. Resident 71, who has dementia and resides on the memory care unit, had a care plan that included supervised activities such as painting, coloring, and bingo. However, the facility did not offer these activities on weekends. Similarly, Resident 13, who is cognitively intact and resides in the same unit, expressed dissatisfaction with the lack of weekend activities, noting that the facility only offered church services once a month on a weekend. The activity calendar for December 2024 showed minimal scheduled activities on weekends, with some days having no activities at all. The only activities listed were Weekend Worksheet Packets, which included word searches and coloring pages. However, Resident 13 reported not receiving these packets, and staff interviews confirmed that the packets were not consistently distributed. The Qualified Medication Aide and Certified Nursing Assistants working on the unit indicated that the facility needed more weekend activities and that the activity staff were only present during weekdays. Interviews with the Unit Manager and the new Activity Director revealed that the facility was aware of the lack of weekend activities and was in the process of addressing the issue. The Activity Director, who had recently started, was informed that there were no weekend activities and was working on hiring staff for weekend and evening activities. The Executive Director also confirmed efforts to hire someone for weekend activities. The facility's Activities Program policy stated that activities should be scheduled daily, including weekends, to meet residents' needs, but this was not being implemented effectively.
Failure to Include Residents and Representatives in Care Plan Conferences
Penalty
Summary
The facility failed to include two residents and their representatives in care plan conferences, as required. Resident 13, who was cognitively intact and diagnosed with heart failure, was not invited to care plan meetings corresponding with his MDS assessments in July and October 2024. Despite the Social Services Director (SSD) claiming that meetings were held and documented, there was no evidence in the electronic health record (EHR) or any signed documentation by Resident 13. The resident himself confirmed he had not attended any care plan meetings and would have signed if he had been present. Similarly, Resident 104, who was severely cognitively impaired with diagnoses including Parkinson's disease and dementia, also did not have documented care plan meetings in line with his MDS assessments. Family Member 3, who was supposed to be involved in the care planning, reported not being invited to any meetings, despite SSD 2's assertion that invitations were extended. The lack of documentation and signatures further supports the absence of proper care plan meetings, contrary to the facility's policy of encouraging resident and representative participation.
Failure to Maintain Catheter Care Standards
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter. The resident, who has a medical diagnosis of obstructive uropathy, was observed on two separate occasions with the urinary catheter drainage bag in contact with the floor while in bed. The resident is dependent on staff assistance for toileting and transferring. A Certified Nursing Assistant confirmed that urinary catheter drainage bags should not be in contact with the ground. The facility's policy on catheter care, provided by the Executive Director, also indicated that the collection bag should not be on the floor.
Misappropriation of Resident's Medication by RN
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's medication, specifically hydrocodone-acetaminophen, by a registered nurse (RN). The clinical record for Resident C, who had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, showed discrepancies in the narcotic sign-off sheet. These discrepancies were noted on multiple occasions, where the count of tablets decreased by two at each instance. A Qualified Medication Aide (QMA) discovered the discrepancies and reported them to the Director of Nursing. Upon investigation, it was revealed that RN 2 admitted to taking two tablets of the narcotic pain medication, administering one to Resident C and keeping one for himself. This occurred on five to six occasions, although Resident C did not go without his prescribed medication. The Executive Director confirmed that the discrepancies were reported, and the RN admitted to the misappropriation of the medication.
Failure to Administer Prescribed Medications from Emergency Drug Kit
Penalty
Summary
The facility failed to provide medications as ordered by the physician for a resident, identified as Resident C, during their stay. The resident's family reported that upon admission, the resident did not receive all prescribed medications. The clinical record review revealed that Resident C had multiple diagnoses, including diabetes, severe protein calorie malnutrition, convulsions, sepsis, major depressive disorder, stiff man syndrome, hypotension, and a pulmonary nodule. Despite these conditions, the resident did not receive several critical medications, including tamsulosin, mirtazapine, amoxicillin, midodrine, pantoprazole sodium, and gabapentin, as ordered on 11/23/24. An interview with the Regional Director of Clinical Operations confirmed that the medications were available in the facility's Emergency Drug Kit (EDK) but were not administered to Resident C. The responsibility to obtain and administer these medications from the EDK fell on the floor nurse who admitted the resident. The facility's policy indicated that emergency pharmacy services were available 24 hours a day, and the emergency medication supply was intended to meet urgent needs. However, the failure to utilize the EDK resulted in the resident not receiving the necessary medications during their stay.
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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) |
|---|---|---|---|---|
| Brickyard Healthcare - Brandywine Care Center | 0.9 mi | ★★★★★ | 11 | 0 |
| Aperion Care Greenfield | 1.2 mi | ★★★★★ | 25 | 0 |
| Springhurst Health Campus | 1.7 mi | ★★★★★ | 1 | 1 |
| Majestic Care Of Mccordsville | 9.8 mi | ★★★★★ | 0 | 0 |
| Morristown Manor | 10.4 mi | ★★★★★ | 0 | 0 |
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