Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Regalcare At Greenfield during CMS and state inspections, most recent first.
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.
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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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.
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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 | ★★★★★ | 12 | 0 |
| Center For Extended Care At Amherst | 15.3 mi | ★★★★★ | 2 | 0 |
| Hadley Pointe Nursing Rehab & Care | 15.5 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.