Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regalcare At Greenfield during CMS and state inspections, most recent first.
Pest control failures allowed flies to persist in the kitchen dish room and spread to Unit Four. Repeated pest reports identified missing grout, broken tiles, and standing water in the dishwashing area as a breeding site, while staff observed flies in the food service area and in a resident room, where open food and drink items were also present. The DON/maintenance leadership acknowledged the ongoing fly problem and that the pest company was not contacted for the Unit Four infestation.
The facility failed to complete required comprehensive MDS assessments and SCSAs within CMS timeframes for six residents. Four residents had annual MDSs completed well past the 14-day deadline after the ARD, and two residents who were admitted to hospice had SCSAs that remained in process beyond the required completion window. The Regional MDS Nurse acknowledged the assessments were not completed on time.
Late Completion of Quarterly MDS Assessments: The facility failed to complete required quarterly MDS assessments for six residents within the CMS timeframe. Several assessments were completed well after the ARD, and two were still incomplete at the time of review. The Regional MDS Nurse acknowledged the assessments were not completed as required.
Food Storage and Kitchen Sanitation Deficiencies: The surveyor observed multiple refrigerated food items that were unlabeled, undated, open to air, or past use-by dates, along with raw eggs and other foods not properly stored. In the main kitchen, shelves, prep surfaces, floors, and dietary carts had dried spills, food debris, stains, and crumbs, and small flies were seen in the area. The FSD stated that expired items should have been discarded and that uncovered, unlabeled, and undated items should have been sealed, labeled, and dated.
Failure to Maintain QAPI for Pest Control: The facility did not maintain an effective QAPI process related to pest control after small flies were identified in the kitchen and later observed in resident areas on Unit Four. Pest control reports documented broken tiles, missing grout, standing water, and repeated fly activity in the dish room, while staff confirmed flies had migrated from one resident’s room into the hallway and another resident’s room. The Administrator stated the facility had not developed a QAPI project related to pest control.
A resident who needed substantial to maximal help with eating was observed during breakfast while a CNA stood beside the resident’s wheelchair and assisted with the meal. The CNA stirred hot cereal, offered spoonfuls of food, and continued assisting while standing, despite acknowledging that she should not have been standing. The UM and DON both stated that staff should be seated when helping residents eat because standing is not dignified.
Failure to coordinate vision services for a resident with DM II, HTN, CKD, and cerebrovascular disease. The resident had an order for optometry as indicated and a signed eye care consent from the HCP, but the resident was not seen by optometry. The HCP said they wanted vision services to ensure the resident’s eyes were not getting worse, and the DON confirmed the resident should have been scheduled and added to the vision provider list.
Failure to Provide Ordered Behavioral Health Services: A resident with TIA, CKD, HTN, and moderate cognitive impairment had a positive depression screen with daily depressed mood, hopelessness, and worthlessness, and the NP entered a psychiatry referral for Major Depressive Disorder. Although the resident had consented to counseling/behavioral health services and had a psych consult order, the record and BH schedule did not show that services were provided, and the SW and DON stated the resident had not been seen timely.
Delayed Follow-Up on Dental Recommendations: A resident with high caries risk and poor oral hygiene had a dental exam that identified plaque, calculus, gingival inflammation, and broken teeth, with specific orders for high-fluoride toothpaste, fluoride rinse, dental cream, and oral rinse. Facility staff did not implement the dentist’s recommendations for several months, the resident said he or she had not been informed of them, and surveyors observed persistent yellow matter and white particles on the teeth while the facility provided a lower-strength fluoride toothpaste than ordered.
The facility failed to provide adequate assistance with ADLs for four residents, specifically in nail care and grooming of unwanted facial hair. Two residents did not receive necessary nail care despite their documented need and requests, resulting in long and dirty fingernails. Another two residents did not receive assistance with facial hair grooming, despite expressing a desire for it. The facility's policies emphasize the importance of providing necessary care, but staff failed to adhere to these policies, leading to unmet care needs.
The facility failed to store medications according to professional standards on the 4th floor unit. Medications were found in sandwich bags without pharmacy labels, contrary to facility policy. Staff interviews revealed that medications should have been sent home or destroyed, as confirmed by the DON. This deficiency indicates a lapse in proper medication management.
A resident with an indwelling urinary catheter was observed with the catheter bag and tubing lying on the floor, contrary to infection control standards. The facility's policy requires the catheter bag to be kept off the floor to prevent contamination. A nurse acknowledged the issue and repositioned the bag, and the DON confirmed the expectation for proper positioning to avoid infection risks.
The facility's Arbitration Agreement failed to include required language about residents' rights to communicate with officials, affecting three residents. The Administrator acknowledged the omission and the need for updates.
A resident with right hip osteoarthritis received the wrong narcotic medication on two occasions due to a nurse's error. The nurse administered Oxycontin instead of the prescribed Oxycodone, resulting in a higher dose of narcotics. The medications were stored in similar blister packs, contributing to the mistake. The errors were discovered during narcotic counts, and the resident reported feeling fine.
A resident was mistakenly administered the wrong narcotic medication on two occasions due to documentation errors. The nurse documented giving PRN Oxycodone but administered scheduled Oxycontin instead. The medications were stored in similar blister packs, contributing to the error. The DON was informed of the incidents.
Pest Control Program Failed to Address Kitchen Fly Breeding and Unit Four Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program after repeated pest control reports identified broken and missing floor tiles, missing grout, and moisture collection in the main kitchen dishwasher area as conditions allowing small flies to breed. The pest control company had documented the same concerns on multiple reviews of the original report, including that nearly all grout in the dishwasher room was missing, there was a gap between the wall and floor that trapped organic debris and moisture, and the area was an ideal breeding ground for flies. The Food Service Director stated the dish room floor had been wet for as long as she could remember and that the missing tiles and grout needed to be fixed. During observation, surveyors saw multiple flies in the food service area during meal tray service and later observed the dishwasher room floor missing six tiles, with a large area of missing grout and pooling liquid in the damaged areas. The surveyor also observed flies on the dish room walls, equipment, and flying overhead. The Director of Maintenance stated he was unaware of the broken tiles, missing grout, and pooling water in the dishwasher room, and he did not know how to retrieve the pest control reports from the portal without assistance. The Administrator stated the missing floor tiles, missing grout, and standing water had been present in the dish room for over a year and that the repairs should have been made when identified by the pest company. The facility also failed to control small flies that had bred and migrated from one resident room into the hallway and into another resident room on Unit Four. Resident #95 had lived in the room since November 2024, and Resident #22 had recently been admitted to the facility. Surveyors observed small flies in Resident #22's room on the privacy curtain and walls, along with open food items including a banana peel and uncovered milk cartons. The resident reported the flies had been present since admission and said no one had helped clean up the food and drink items. Staff observed the flies in the room and hallway, and the Maintenance Director acknowledged that the flies had been a problem in Resident #95's room, had migrated into the hallway and Resident #22's room, and that the facility had not contacted the pest control company when the small flies were identified on Unit Four.
Late MDS and SCSA Completion
Penalty
Summary
The facility failed to complete comprehensive assessments within the timeframe required by the CMS RAI Manual for six residents. Annual MDS assessments for Residents #5, #133, #82, and #98 were completed well after the 14-day deadline following their assessment reference dates. Resident #5 had an annual MDS with an ARD of 3/4/26 that was not completed until 4/16/26, and Residents #133, #82, and #98 each had annual MDS assessments with an ARD of 2/25/26 that were not completed until 4/16/26. The record review showed these assessments were completed 43 to 50 days after the ARDs. The facility also failed to complete significant change in status assessments for Residents #122 and #9 within 14 days after the determination that a significant change occurred. Resident #122 signed on to hospice services on 3/18/26 and had a comprehensive SCSA with an ARD of 3/25/26 that was still in process as of 4/16/26. Resident #9 had a physician order for hospice services on 3/13/26 and had a comprehensive SCSA with an ARD of 3/13/26 that was still in process as of 4/22/26. During interview, the Regional MDS Nurse stated that the comprehensive MDS assessments for these residents were not completed within the required timeframe and should have been.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete non-comprehensive quarterly MDS assessments within the timeframe required by the CMS RAI manual for six residents out of a sample of 24. Review of the records showed that Residents #34, #115, #3, #124, #138, and #105 each had a quarterly MDS with an ARD that required completion no later than 14 calendar days after the ARD, but the assessments were completed well after that timeframe or were still not complete at the time of review. Resident #34, admitted in July 2019, had a quarterly MDS with an ARD of 2/25/26 that was not completed until 4/16/26. Resident #115, admitted in December 2021, had a quarterly MDS with an ARD of 3/11/26 that was not complete as of 4/21/26. Resident #3, admitted in December 2022, had a quarterly MDS with an ARD of 3/4/26 that was not completed until 4/16/26. Resident #124, admitted in November 2024, had a quarterly MDS with an ARD of 2/5/26 that was not completed until 4/16/26. Resident #138, admitted in November 2025, had a quarterly MDS with an ARD of 2/25/26 that was not completed until 4/16/26. Resident #105, admitted in December 2025, had a quarterly MDS with an ARD of 3/18/26 that was not complete as of 4/21/26. During interview, the Regional MDS Nurse stated these assessments were not completed within the required timeframe and should have been.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to follow professional standards of practice for food storage and environmental cleaning in the main kitchen. During the initial kitchen walk-through, the surveyor observed multiple food items in the reach-in refrigerator that were covered but unlabeled and undated, including bowls of salad, containers with orange-colored and white-colored substances, and covered plates of wilted salad. In the walk-in refrigerator, the surveyor observed food items with use-by dates that had passed, including rice pilaf, noodles, and mushrooms, along with other items that were open to air, unlabeled, undated, or otherwise not properly stored, such as cheesecake, dried meat product, sliced pears, yellow cake, hot dogs, sour cream, shredded cheese, sausage patties, thawed spinach, ham, tortillas, staff soda, and raw eggs. In the main kitchen food preparation area, the surveyor observed multiple shelves of stacked pots, bowls, and sieves with dried white powder-like substance and water stains on the shelf surfaces. Small flies were seen flying around the kitchen area. The surveyor also observed a used dirty spatula and three hard plastic cups on the kitchen floor, a food preparation table with plastic tubs and lids covered in food debris, crumbs and discarded items on the floor, dried splatters and spills on the floor and oven surface, and two dietary trolley carts with dried stains, opened sugar packets, and food crumbs on the shelves. During interview, the Food Service Director reviewed the concerns and stated that items with specific use-by dates should have been thrown away by the listed dates, and that uncovered, unlabeled, and undated items should have been sealed, labeled, and dated. The Food Service Director also stated that the kitchen surfaces were not sanitary and should have been because unsanitary surfaces have the potential to make someone sick if they are not clean.
Failure to Maintain QAPI for Pest Control
Penalty
Summary
The facility failed to maintain an effective QAPI program related to pest control. The report states that small flies were identified in the main kitchen in October 2025, and the pest control company recommended repairs to broken floor tiles and missing grout, removal of organic debris and standing water, and bi-weekly treatment for flying insects. Despite these recommendations, the same conditions remained present months later, including standing water, missing grout, and broken tiles around the dish room drain. Survey observations on 4/16/26 and 4/22/26 found small flies in the kitchen food preparation and dish room areas. The pest control company’s reports documented repeated findings of missing grout, gaps between the wall and floor, water leaking, and fly activity in the dishwashing area, including several dozen flies observed in February 2026. The company also stated that the facility’s pest service contract did not include flying insect treatment unless added, and that no further services for small flies had been requested after the October 2025 service. Small flies were also observed on Unit Four in resident areas. Resident #22 reported flies in the room since admission, and surveyors observed multiple small flies on the privacy curtain and walls in the resident’s room, as well as flies in the hallway outside the room. Staff interviews confirmed that flies had been a problem in Resident #95’s room and had migrated into the hallway and into Resident #22’s room. The Maintenance Director and Administrator stated that the facility had not contacted the pest control company about the Unit Four flies, and the Administrator said the facility had not developed a QAPI project related to pest control.
Dignified Dining Assistance Not Provided
Penalty
Summary
The facility failed to ensure a dignified dining experience for one resident during breakfast when a CNA stood beside the resident’s wheelchair while assisting with the meal. The resident was admitted in November 2024 with diagnoses including hemiplegia affecting the right dominant side, major depressive disorder, and diabetes mellitus type II. The resident’s MDS assessment indicated cognitive impairment with a BIMS score of 9 out of 15 and the need for substantial to maximal assistance for eating, and the person-centered nutrition care plan included meal tray set-up and additional assistance as needed. During observation in the third-floor dining room, the resident was seated in a wheelchair at a table with other residents while the CNA stirred a bowl of hot cereal and offered spoonfuls of food while standing next to the resident. The CNA walked away to assist another resident and later returned to continue assisting the resident while still standing. The UM observed the interaction and stated that standing while assisting was probably not dignified, and later confirmed that staff should not stand while assisting residents with meals. The CNA stated that she sometimes stands while assisting residents so she can keep an eye on others in the dining area, and acknowledged that she should not have been standing while assisting the resident with breakfast. The DON stated that all staff should be seated when assisting residents with a meal and that standing does not provide a dignified experience.
Failure to Coordinate Vision Services
Penalty
Summary
The facility failed to coordinate vision care services for Resident #79, who was admitted with diagnoses including Type 2 diabetes mellitus with diabetic chronic kidney disease, essential primary hypertension, long-term insulin use, and cerebrovascular disease. The resident’s record included an ancillary order indicating the resident may be seen by optometry as indicated, and the Minimum Data Set showed the resident had moderate cognitive impairment, was usually understood and understood others, and had adequate vision with corrective lenses. The clinical record also included a consent form for eye care services signed by the resident’s HCP. During observation on 4/16/26, the resident was seen seated in a wheelchair wearing eyeglasses with the HCP present. The HCP stated a desire for the resident to be seen for vision services to ensure the resident’s eyes were not getting worse and said the facility had not informed the HCP that the resident had been seen by optometry. The DON later stated the resident had not been seen for vision services and should have been seen, and explained that residents who sign a consent form for vision services are scheduled by the facility and should have been added to the list for the vision service provider after admission.
Failure to Provide Ordered Behavioral Health Services
Penalty
Summary
The facility failed to ensure Behavioral Health Services were provided for a resident who had a change in condition and was screened positive for Major Depressive Disorder. The resident was admitted with diagnoses including TIA, CKD stage three, and hypertension, had consented to receive counseling or behavioral health services, and had a care plan that called for monitoring the need for psychological or psychiatric support and providing services as ordered. The resident’s MDS showed moderate cognitive impairment, and the physician’s orders included a psychiatry consult for depression and that the resident may be seen by psych as indicated. On 3/17/26, the NP documented daily depressed mood, hopelessness, and worthlessness, recorded a positive depression screening, and entered a treatment plan requiring referral to psychiatry/behavioral health with a plan to refer to Psychiatry for Major Depressive Disorder. However, the facility’s behavioral health schedule for March and April 2026 did not show that the resident received any Behavioral Health Services, and the medical record did not show an evaluation by Behavioral Health Services as ordered. During interviews, the resident stated feeling very depressed and unsupported by staff, the SW said the resident had not been seen because the behavioral health team had been busy with new admissions, and the DON stated the resident had not been seen timely and that this resulted from poor communication between nursing staff and the administrative team.
Delayed Follow-Up on Dental Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up dental services for one resident in the sample, Resident #2, after a January 2026 dental evaluation identified multiple oral care needs. The dental consultant documented soft plaque and food debris buildup, heavy hard calculus deposits, moderate gingival inflammation with swollen and bleeding gums, fair periodontal condition, and high caries risk. The dentist also noted broken teeth and severe buildup along the maxillary teeth that covered tooth surfaces, and recommended fluoride every six months, exam and prophylaxis, silver diamine fluoride, and oral aids to prevent further breakdown. The dentist’s written action items for nursing home staff included continuing daily oral care and implementing several specific oral hygiene measures: Prevident fluoride toothpaste, brushing with OTC fluoride rinse prior to bed, applying Remin Pro dental cream once daily, and using molecular iodine oral rinse twice daily to decrease buildup on the upper teeth. The facility did not initiate these dental recommendations until four months later, and the record showed that the fluoride rinse mouth/throat solution was not added to the resident’s medication profile until after surveyor interviews. During the survey, the resident stated that he or she had not been informed of the dentist’s recommendations and was still waiting for staff to provide them. Observation and interview findings showed the resident’s teeth remained coated with yellow matter and white particles between the teeth on multiple dates during the survey. The resident also reported broken teeth in the upper left side of the mouth. The facility provided a fresh mint anticavity fluoride toothpaste that contained approximately 1,000 ppm fluoride, which was less than the 5,000 ppm fluoride toothpaste recommended by the dentist. Facility staff acknowledged that the dental recommendations had been missed, and the DON stated that there should have been physician orders to address the dentist’s recommendations.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents, specifically in the areas of nail care and grooming of unwanted facial hair. Residents #41 and #84 did not receive necessary nail care assistance, despite their documented need for such support. Resident #41, who was moderately cognitively impaired, had long fingernails with dark debris underneath, and expressed a desire for nail care, which was not provided. Similarly, Resident #84, who was cognitively intact but unable to maintain their nails due to edema, had long and jagged fingernails that were not attended to despite requests for assistance. Residents #9 and #19 did not receive assistance with grooming unwanted facial hair. Resident #9, who was severely cognitively impaired, was observed with facial hair under the chin and expressed a desire for it to be removed, yet staff did not provide this care until prompted by the surveyor. Resident #19, who was cognitively intact, also expressed a preference for facial hair removal, but staff did not offer assistance, and the facial hair remained visible during multiple observations. The facility's policies on ADLs and dignity emphasize the importance of providing necessary care and respecting residents' grooming preferences. However, the observations and interviews indicate a failure to adhere to these policies, resulting in unmet care needs for the residents involved. Staff interviews revealed a lack of communication and follow-through in providing the required assistance, contributing to the deficiencies observed by the surveyors.
Improper Medication Storage on 4th Floor Unit
Penalty
Summary
The facility failed to ensure that medications were stored according to professional standards of practice on the 4th floor unit. During an observation, surveyors found multiple medications stored in sandwich bags, which were rubber-banded together with a resident's name attached. These bags contained pieces of paper indicating the medication names but lacked any pharmacy packaging or labels. This method of storage did not comply with the facility's policy, which requires drugs and biologicals to be stored in the packaging or containers in which they are received, and only the issuing pharmacy is authorized to transfer medications between containers. Interviews with staff revealed a lack of adherence to proper medication storage protocols. Nurse #1 acknowledged that medications should not be stored in sandwich bags and should have been either sent home with the resident's family or destroyed upon receipt. The Director of Nursing (DON) confirmed that medications received in such storage should be destroyed immediately, as they could not be accurately identified or verified as prescribed for the resident. This deficiency highlights a significant lapse in medication management on the 4th floor unit, as medications were not stored in pharmacy-approved and labeled containers, nor were they accurately labeled for precautions and safe administration.
Infection Control Deficiency: Improper Catheter Bag Positioning
Penalty
Summary
The facility failed to adhere to infection control standards for Resident #19, who had an indwelling urinary catheter. The deficiency was observed when the urinary catheter bag and tubing were found lying on the floor, contrary to the facility's policy and best practices for infection prevention. The AHRQ guidelines emphasize that the catheter can serve as a pathway for microbes to enter the bladder, increasing the risk of infection. The facility's policy, revised in April 2022, clearly states that the drainage bag should be kept below the bladder level and off the floor to prevent contamination. During the survey, Resident #19 was observed twice with the catheter bag and tubing on the floor, once in the morning and again in the afternoon. The resident was cognitively intact, with a BIMS score of 13, and had been admitted with diagnoses including obstructive and reflex uropathy. Nurse #2 acknowledged the improper positioning of the catheter bag and took immediate action to reposition it off the floor. The Director of Nursing confirmed that the expectation was for the catheter equipment to be kept off the floor to avoid infection risks.
Arbitration Agreement Lacks Required Communication Rights Language
Penalty
Summary
The facility failed to ensure that its Arbitration Agreement contained specific language required by regulations, which pertains to the communication rights of residents or their representatives with federal, state, or local officials. This deficiency was identified for three residents, whose signed Arbitration Agreements did not explicitly state that they maintained the right to communicate with officials such as federal and state surveyors, health department employees, and representatives of the Office of the State Long Term Care Ombudsman. The review of the facility's Admission Packet and the signed Arbitration Agreements for these residents revealed the absence of this critical information. During interviews, the facility's Administrator acknowledged that the Arbitration Agreements lacked the necessary components to inform residents or their representatives of their rights to communicate with relevant officials. The Administrator admitted that the agreements needed updating to include this information, confirming the deficiency in the facility's documentation process. This oversight affected the residents' ability to be fully informed of their rights regarding communication with regulatory and oversight bodies.
Medication Administration Error with Narcotics
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a nurse administered the wrong narcotic medication on two separate occasions. The resident, who was admitted with a diagnosis of right hip osteoarthritis, had physician's orders for two different narcotic medications: Oxycontin, to be given twice daily, and Oxycodone, to be given as needed every four hours. On both occasions, Nurse #4 mistakenly administered Oxycontin instead of the prescribed Oxycodone, resulting in the resident receiving a higher dose of narcotics than intended. The errors occurred during the night shift when Nurse #4, who was responsible for medication administration, selected the wrong medication from the narcotic box. The nurse reported that the medications were stored in blister packs next to each other and were the same color, which may have contributed to the mistake. The errors were documented in the Medication Variance Reports and were discovered during the narcotic count at the change of shift. Despite the errors, the resident reported feeling fine after the incidents.
Medication Administration Errors Due to Documentation Inaccuracy
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident who was prescribed two different narcotic pain medications: Oxycontin, a scheduled medication, and Oxycodone, a PRN (as needed) medication. On two separate occasions, Nurse #4 documented administering the PRN Oxycodone, but instead dispensed and administered the scheduled Oxycontin in error. This discrepancy was noted in the Medication Administration Record (MAR) and confirmed by the Medication Variance Reports, which were signed by Nurse #4. The errors occurred because the narcotic medications were stored in blister pack cards next to each other, and both medications were the same color, leading to confusion. Nurse #4, who worked the night shift, admitted to mistakenly pulling the wrong medication card on both occasions. The Director of Nurses was informed of these medication errors and emphasized the expectation for nurses to administer medications as ordered and document accurately.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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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) |
|---|---|---|---|---|
| Charlene Manor Extended Care Facility | 0.8 mi | ★★★★★ | 3 | 0 |
| Poet's Seat Healthcare Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Vernon Green Nursing Home | 13.7 mi | ★★★★★ | 14 | 0 |
| Center For Extended Care At Amherst | 15.3 mi | ★★★★★ | 2 | 0 |
| Hadley Pointe Nursing Rehab & Care | 15.5 mi | ★★★★★ | 23 | 0 |
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