Below 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 Edgewood Manor Of Greenfield during CMS and state inspections, most recent first.
A resident with dementia and other diagnoses was dependent on staff for bathing and was scheduled for showers twice weekly, but the bathing record showed a 10-day period with no documentation that a bath or shower was offered, received, or refused. The DON confirmed the gap and could not explain why it occurred. Facility policy required documentation of completed bathing, refusals, and interventions.
A resident with dementia, anxiety disorder, and a history of intracerebral hemorrhage had a fall risk care plan that included keeping the call light in reach. Surveyors observed the resident’s touch pad call light on the floor under the room divider curtain on two occasions, including while the resident was in bed, and an LPN confirmed it was not within reach.
The facility failed to maintain proper sanitation and food safety standards, affecting all residents. The dishwasher operated below required temperatures, and a staff member mishandled food with contaminated gloves, violating facility policies. Additionally, the kitchen's ventilation cover was unclean.
The facility failed to promptly resolve dietary grievances, affecting all 50 residents. Grievance logs showed multiple complaints about food quality and quantity, with resolutions listed as staff education and offering alternatives, but no evidence of education was provided. Residents expressed dissatisfaction with the food, describing it as bland and unappetizing. The Administrator acknowledged the complaints, attributing them to contracted dietary staff, and admitted to not testing the food for quality.
The facility did not adhere to the menu guidelines during meal service, affecting all 50 residents. Regular diet residents received incorrect portions of potatoes, and mechanical soft diet residents received incorrect portions of both potatoes and country fried steak. A staff member confirmed these discrepancies, which were contrary to the facility's menu policy.
The facility failed to maintain a clean and sanitary environment, affecting all 50 residents. Observations revealed missing light covers, exposed fluorescent lighting, and damaged ceilings. Additionally, a resident's room had a strong odor of urine and debris, while another had stains on the wall and a soiled floor. These conditions were confirmed by an LPN during interviews and observations.
The facility failed to submit MDS assessments within the required timeframe for five residents, with delays in completion and submission ranging from several weeks to missing assessments entirely. The MDS Coordinator confirmed the delays and acknowledged the requirement for timely submission.
The facility failed to develop comprehensive care plans for four residents, leading to deficiencies in addressing their medical and psychosocial needs. Two residents on anticoagulant medication lacked care plans for its use, another resident had no care plan for dental needs despite being edentulous, and a fourth resident at risk for social isolation had no activities care plan. Staff interviews confirmed these omissions.
The facility failed to prepare mashed potatoes in a palatable manner, affecting four residents. During meal service, a staff member served mashed potatoes that included dry potato mix, indicating they were not thoroughly mixed. An interview confirmed this issue, and a review of the recipe showed the proper mixing process was not followed.
The facility failed to prepare mechanically altered meat in a suitable form for residents on mechanical soft diets. During meal service, large chunks of country fried steak were served, which were inappropriate for these diets. A staff member confirmed serving these improperly sized portions to residents, affecting 11 individuals in the facility.
The facility failed to notify the state mental health authority of significant changes in the mental health conditions of two residents, as required by PASARR. One resident received a new diagnosis of schizoaffective disorder, and another was diagnosed with paranoid schizophrenia, but no updated PASARRs were completed. The Social Services Director confirmed these oversights, indicating non-compliance with PASARR requirements.
A resident with multiple diagnoses, including rheumatoid arthritis, was admitted with a wound on her left ankle, which the facility failed to identify and treat until five days post-admission. Interviews with staff confirmed the oversight, and the wound physician's assessment was delayed. The facility did not adhere to its wound care policy, which required timely verification of physician orders and care plan reviews.
A resident, who required maximum assistance with eating due to conditions like rheumatoid arthritis, was not provided with a divided plate as ordered by the physician. Instead, the meal was served on a regular plate, contrary to the facility's policy on assistive devices. This oversight was confirmed by the staff involved.
A facility failed to implement enhanced barrier precautions for a resident with a tracheostomy, as required by their policy. The resident, who had a complex medical history, did not have the necessary signage or PPE available outside their room, despite a physician's order for such precautions. This deficiency was observed on multiple occasions.
The facility failed to administer pneumococcal vaccines timely to two residents, despite their medical conditions warranting it. Both residents had no documented evidence of receiving the vaccine by the review date, and the ADON confirmed the oversight. The facility's policy requires vaccine assessment upon admission and annual checks, which were not adhered to in these cases.
The facility failed to provide a safe and functional environment, with surveyors observing multiple damaged and non-functional gutter systems around the building and a large brown stain on a resident room ceiling. The Administrator confirmed these issues and stated that repair estimates had been obtained but were awaiting corporate approval.
Missed Scheduled Bathing for a Dependent Resident
Penalty
Summary
Resident #32, who was admitted on 11/07/25 with diagnoses including nontraumatic intracerebral hemorrhage, dementia, anxiety disorder, and psychoactive substance abuse, was dependent on staff for bathing, dressing, and toileting hygiene. The resident’s Medicare 5-day MDS assessment showed a BIMS score of 10 out of 15, indicating moderately impaired cognition for daily decision-making abilities. The facility’s bathing schedule showed the resident was to receive a bath or shower twice weekly on Wednesday and Saturday nights. Review of the bathing task record from 03/01/26 through 05/24/26 showed a 10-day span from 03/25/26 through 04/05/26 during which no bath or shower was documented as offered, received, or refused. The resident remained in the facility during that time. The DON confirmed during interview that there was a 10-day period when Resident #32 was not documented as having received or been offered a bath or shower and stated they were not sure why this occurred. The facility policy on Shower/Tub Bath states the purpose is to provide cleanliness, comfort, and observation of skin condition, and requires documentation of the date and time of the bath or shower, the assisting staff member, and any refusal or interventions taken.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure a call light was within reach for Resident #32, who was admitted with diagnoses including nontraumatic intracerebral hemorrhage, dementia, anxiety disorder, and psychoactive substance abuse. The resident’s care plan identified a fall risk and included keeping the call light in reach, and the MDS showed a BIMS score of 10 out of 15 with dependence on staff for bathing, dressing, and toileting hygiene. During observation, the resident’s push pad/touch pad call light was found on the floor under the room divider curtain and not within reach on two separate occasions, including when the resident was in bed with the bed in the lowest position, one side against the wall, and a fall mat on the floor. An LPN later verified that the call light was on the floor and not within reach, and stated that call lights should be within reach at all times.
Sanitation and Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to ensure food was served in a safe and sanitary manner, affecting all 50 residents. During an observation of the kitchen, it was noted that the dishwasher was operating with a wash temperature of 111 degrees Fahrenheit and a rinse temperature of 146 degrees Fahrenheit, both below the required minimum of 120 degrees Fahrenheit as per the dishwasher's operations manual. The chemical sanitizer tested at 200 parts per million, which was verified by the Dietary Manager. The facility's policy required dishwasher water temperatures to be maintained according to manufacturer recommendations, which was not adhered to. Additionally, the kitchen's ventilation cover above the sink was observed to have a gray fuzzy substance built up on it, indicating a lack of proper cleaning. During a meal tray line observation, a staff member was seen handling food with contaminated gloves, failing to change gloves or wash hands after contact with soiled surfaces, and using a soiled plate to serve a meal. The staff member also blew into a new pair of gloves before putting them on, further compromising sanitation. These actions were in violation of the facility's policies on warewashing and food preparation, which required proper handwashing techniques and glove use.
Failure to Resolve Dietary Grievances Promptly
Penalty
Summary
The facility failed to promptly resolve dietary grievances, affecting all 50 residents. The grievance logs from October to December 2024 showed multiple complaints about dietary services, including food quality and quantity. Resolutions were listed as educating staff and offering alternatives, but there was no evidence of education being provided to dietary staff. Interviews with several residents revealed dissatisfaction with the taste and preparation of the food, describing it as bland and unappetizing. The facility's grievance policy required follow-up within 72 hours and resolution within 30 days, but ongoing complaints indicated these measures were ineffective. The Administrator acknowledged the persistent complaints and attributed them to the contracted dietary staff, stating the facility could only communicate concerns to the contractor. The Administrator admitted to not testing the food for quality and lacked proof of staff education. An LPN confirmed ongoing complaints about cold food and small portions, noting the food appeared unappetizing. The deficiency was investigated under Complaint Number OH00161251, highlighting the facility's non-compliance with grievance resolution requirements.
Non-Compliance with Menu Guidelines During Meal Service
Penalty
Summary
The facility failed to ensure that menus were followed during meal service, affecting all 50 residents. On the date of observation, residents on regular diets were supposed to receive one country fried steak with mushroom gravy, four ounces of carrots, four ounces of potatoes, and a square of cornbread. Residents on mechanical soft diets were to receive a four-ounce scoop of ground country fried steak with mushroom gravy, four ounces of carrots, four ounces of potatoes, and a square of cornbread. However, during the meal service, residents on regular diets were served one country fried steak, three ounces of gravy, four ounces of carrots, three ounces of potatoes, and a square of cornbread. Residents on mechanical soft diets received three ounces of mechanically altered country fried steak, three ounces of gravy, four ounces of carrots, three ounces of potatoes, and a square of cornbread. An interview with a staff member confirmed the discrepancies between the served portions and the menu spreadsheet. The staff member verified that residents on regular diets were served a three-ounce scoop of potatoes instead of the four ounces indicated on the menu. Similarly, residents on mechanical soft diets were served three ounces of potatoes and three ounces of mechanically altered country fried steak, contrary to the menu's specification of four ounces each. The facility's menu policy, dated October 2022, stated that menus were to be served as written, highlighting the non-compliance with the established guidelines.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment, affecting all 50 residents. During an interview and observation with the Administrator, it was confirmed that several light fixtures in the facility were missing covers, exposing fluorescent lighting. Additionally, there were missing ceiling tiles and damage to the ceiling in certain hallways, and several lights were out in the resident living room and hallways. These observations were confirmed by the Administrator at the time of the survey. Further deficiencies were noted in the living conditions of individual residents. One resident's room had a strong odor of urine, scattered debris, and a dirty floor, as confirmed by an LPN. Another resident's room had brown and reddish stains splattered on the wall next to the bed, and the floor appeared soiled and unkempt. These conditions were also confirmed by the same LPN during an interview and observation. The medical records of these residents indicated various health conditions, including diabetes, hypertension, and cognitive impairments, which necessitated varying levels of assistance from the staff.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were encoded and transmitted within the required timeframes, affecting five residents. Resident #17's quarterly MDS assessment was completed on August 13, 2024, but not submitted until September 24, 2024. Resident #5's MDS assessment was completed on September 9, 2024, and submitted on September 24, 2024, after the resident had already been discharged. Resident #30 did not have a discharge MDS assessment completed, despite being discharged on August 30, 2024. Resident #27's admission MDS assessment was completed on August 30, 2024, but not submitted until September 24, 2024. Resident #11's annual MDS assessment was completed on September 6, 2024, and submitted on September 24, 2024. In each case, the MDS Coordinator verified the delays and acknowledged that the assessments should have been completed and submitted within the required seven-day timeframe.
Deficiencies in Care Plan Development for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for four residents, which led to deficiencies in addressing their specific medical and psychosocial needs. Resident #12, who was admitted with multiple diagnoses including schizoaffective disorder and atrial fibrillation, was receiving an anticoagulant medication, Eliquis, but did not have a care plan addressing its use. Similarly, Resident #42, with diagnoses including a wedge compression fracture and atrial fibrillation, was also on Eliquis without a corresponding care plan. Interviews with MDS Nurse #328 confirmed the absence of care plans for anticoagulant use for both residents. Resident #39, diagnosed with end-stage renal disease and other conditions, was edentulous and used dentures, yet lacked a care plan addressing dental needs. Additionally, Resident #24, with diagnoses including congestive heart failure and major depressive disorder, was at risk for social isolation and had expressed little interest in activities. Despite this, there was no care plan developed to address her activity needs. The Activities Director #325 confirmed the absence of an activities care plan for this resident.
Improper Preparation of Mashed Potatoes
Penalty
Summary
The facility failed to prepare food in a palatable and attractive manner, specifically affecting four residents who received mashed potatoes during meal observations. During a meal service observation, a staff member served mashed potatoes using a four-ounce scoop, but part of the scoop contained dry potato mix, indicating the mashed potatoes were not thoroughly mixed. An interview with the staff member confirmed that residents were served dry mashed potato mix in their mashed potatoes. A review of the facility's undated mashed potato recipe revealed instructions to mix the dry potato mix and water together, add margarine, and mix thoroughly. However, this process was not followed, leading to the deficiency.
Improper Preparation of Mechanically Altered Diets
Penalty
Summary
The facility failed to ensure that mechanically altered meat was prepared in a form suitable for residents on mechanical soft diets. During an observation of meal service, it was noted that the mechanically altered country fried steak contained large chunks, larger than the size of a quarter, which were not appropriate for residents requiring mechanically altered diets. A staff member, identified as [NAME] #406, confirmed serving these improperly sized chunks to residents on mechanical soft diets. This deficiency affected 11 residents who were on mechanically altered diets, out of a facility census of 50.
Failure to Notify State Mental Health Authority of Significant Changes in Residents' Conditions
Penalty
Summary
The facility failed to notify the state mental health authority of significant changes in the mental health conditions of two residents, which is a requirement under the Preadmission Screening and Resident Review (PASARR) process. Resident #33 was admitted with several diagnoses, including major depressive disorder and a history of traumatic brain injury. Despite a new diagnosis of schizoaffective disorder in August 2023, the facility did not complete a significant change PASARR or notify the state mental health authority. Additionally, the major depressive disorder diagnosis was not included in the PASARR completed in November 2021. Similarly, Resident #2, who was admitted with multiple diagnoses including dementia and major depressive disorder, received a new diagnosis of paranoid schizophrenia in April 2022. However, the facility did not complete a new PASARR following this significant change in the resident's mental health condition. The Social Services Director confirmed that no updated PASARRs were completed for either resident following their new diagnoses, indicating a lapse in the facility's compliance with PASARR requirements.
Failure to Timely Assess and Treat Resident's Wound
Penalty
Summary
The facility failed to properly assess and treat a non-pressure wound on a resident's left ankle in a timely manner. The resident, who was admitted with multiple diagnoses including rheumatoid arthritis and chronic pain syndrome, had a wound documented in the hospital discharge report. However, the facility did not identify or provide treatment for the wound until several days after admission. The initial wound care assessment was conducted five days post-admission, during which necrotic tissue was removed and a treatment plan was established. Interviews with facility staff, including the MDS Nurse, ADON, and the admission LPN, confirmed the oversight in identifying and treating the wound. The wound physician's first assessment occurred five days after admission, and although the physician did not believe the delay caused further damage, the facility's failure to follow its wound care policy was evident. The policy required verification of a physician's order and a review of the resident's care plan for any special needs, which was not adhered to in this case.
Failure to Provide Assistive Eating Equipment
Penalty
Summary
The facility failed to provide a resident with the required assistive eating equipment as per the physician's order. Resident #37, who was cognitively intact but required maximum assistance with eating, was ordered to have a divided plate for all meals due to her medical conditions, which included rheumatoid arthritis and chronic pain syndrome. However, during a meal service observation, staff member #406 served the resident's meal on a regular plate instead of the prescribed divided plate. This was confirmed through an interview with the staff member, who acknowledged the oversight. The facility's policy on assistive devices, which mandates the provision of such devices as identified in the individualized plan of care, was not adhered to in this instance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures for a resident with an indwelling medical device who was placed on enhanced barrier precautions. Specifically, the facility did not display the required signage indicating enhanced barrier precautions on or near the resident's room door, nor was personal protective equipment (PPE) available outside the room. This deficiency was observed on multiple occasions, including on January 21 and January 22, 2025, affecting one of the five residents reviewed for infection control. Resident #9, who was affected by this deficiency, had a complex medical history including chronic obstructive pulmonary disease, tracheostomy status, and other significant health conditions. The resident was cognitively intact and required tracheostomy care. Despite having a physician's order dated October 3, 2024, for enhanced barrier precautions due to the tracheostomy, the facility did not adhere to its own policy dated August 1, 2022, which mandates the posting of signs and availability of PPE for residents with indwelling medical devices to prevent the spread of multi-drug resistant organisms.
Failure to Administer Pneumococcal Vaccines Timely
Penalty
Summary
The facility failed to timely administer pneumococcal vaccines to two residents, affecting their compliance with vaccination protocols. Resident #11, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, diabetes mellitus with diabetic neuropathy, and vascular dementia, had no documented evidence of receiving a pneumococcal vaccine as of January 23, 2025. Similarly, Resident #29, admitted with conditions such as chronic obstructive pulmonary disease, hemiplegia following cerebral infarction, and chronic pain syndrome, also lacked documentation of receiving the pneumococcal vaccine by the same date. An interview with the Assistant Director of Nursing (ADON) confirmed that both residents had not received the pneumococcal vaccine during their stay, although they were supposed to receive it on the day of the interview. The facility's policy, dated October 1, 2023, mandates that residents be assessed for vaccine eligibility upon admission and offered the vaccine series within 30 days unless contraindicated or previously completed. The ADON acknowledged that the vaccine status should be checked on admission and annually, indicating a lapse in adherence to the facility's vaccination policy.
Facility Failed to Maintain Safe and Functional Environment
Penalty
Summary
The facility failed to provide a safe and functional environment for its residents, as evidenced by multiple observations of damaged and non-functional gutter systems around the building. On 05/01/24, surveyors observed rain gutters hanging unattached to the fascia board on the left side front of the building near a resident room, outside the main entrance above the business office, and at the back of the building near a resident courtyard. Additionally, a large brown stain was observed on the ceiling above the window in a resident room, indicating potential water damage. The Administrator confirmed these issues and stated that several estimates for repairs had been obtained over the past year, but corporate approval was still pending. This deficiency was investigated under Complaint Number OH00152896.
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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) |
|---|---|---|---|---|
| Greenfield Skilled Nursing And Rehabilitation | 0.6 mi | ★★★★★ | 10 | 0 |
| Embassy Of Valley View | 9.4 mi | ★★★★★ | 2 | 0 |
| Vineyards At Concord, The | 11.8 mi | ★★★★★ | 33 | 0 |
| Copper Knoll Health & Rehab Llc | 13 mi | ★★★★★ | 13 | 0 |
| Court House Manor | 14.2 mi | ★★★★★ | 0 | 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.