Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple comorbidities, total dependence for mobility and ADLs, and an existing buttock pressure ulcer did not receive timely preventive interventions such as an air mattress, pressure-relieving wheelchair cushion, or offloading despite documented risk and ulcer presence. The resident was moved from a motorized wheelchair with a pressure-reducing cushion to a standard wheelchair without adding comparable pressure-relief measures, and the comprehensive care plan initially lacked specific skin integrity interventions. Over several weeks, an LPN who was not wound certified documented weekly skin grid assessments and staged the ulcer as it worsened in size and drainage, but there was no documented RN or physician assessment or verification of staging, and no evidence of communication to an RN or physician about the ulcer during that period, contrary to facility policy and state nursing practice standards.
Failure to assess self-administration of topical medication: A cognitively intact resident with edema, a venous ulcer, cellulitis, and skin cancer history was found self-applying triamcinolone cream at the bedside even though the order did not authorize self-administration. The chart lacked a self-administration assessment and care plan at the time of review, while MARs showed nursing documentation of administration. An LPN confirmed the resident was using the cream on a biopsy site that did not have a treatment order, and the assessment was only completed after the issue was brought to the facility’s attention.
Failure to develop a tube feeding care plan for a resident with a new G-tube and enteral feedings. The resident had multiple chronic conditions, including DM2, COPD, protein-calorie malnutrition, and CVA, and was receiving Two Cal via tube for dysphagia with ordered flushes, placement checks, and daily site care. The MDS coordinator confirmed the tube feeding care plan was not in place until months after the resident had already been receiving tube feedings.
Incorrectly Transcribed Catheter Order During Voiding Trial: A resident with DM, CKD stage 3, and obstructive/reflux uropathy had a Foley removed for a voiding trial, but the prescriber’s straight cath order was transcribed incorrectly and not clarified. Documentation showed straight cath output of 850 mL and later 1400 mL with abdominal pain and distention, while the DON and NP confirmed the intended threshold was 400 mL, not 2400 mL, and the MAR showed limited straight cath documentation.
The facility did not properly hold, secure, and manage a resident's personal money that was deposited with the facility, resulting in improper handling of the resident's funds.
The facility did not ensure that a resident was protected from the wrongful use of their belongings or money, resulting in a deficiency related to safeguarding personal property and financial resources.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences.
The facility failed to store and serve food safely, affecting all 42 residents. Expired milk was found in the kitchen, and the Dietary Manager was observed serving food without proper hygiene, including not changing gloves and not wearing a facial hair restraint. These actions violated the facility's food handling policies.
The facility failed to provide adequate food portions as per the menu for residents on mechanical soft and pureed diets. Observations revealed discrepancies in the portions served, with residents receiving less roast beef and missing pureed bread. The Dietary Manager confirmed these inconsistencies during the tray line observation.
The facility failed to provide prescribed controlled carbohydrate diets to 15 residents, serving regular syrup instead of reduced calorie syrup due to a shortage. Staff interviews confirmed the lack of reduced calorie syrup, and the Dietary Manager was unaware of the shortage, violating the facility's policy on therapeutic diets.
A resident's MDS assessments were inaccurately coded as using an invasive mechanical ventilator, despite the resident using a non-invasive BiPAP machine. The error persisted across multiple assessments, and staff interviews confirmed the mistake. The resident's medical history included chronic respiratory conditions, and physician orders specified the use of a non-invasive AVAPS machine.
A facility failed to accurately document a resident's anxiety diagnosis in the PASARR, despite it being present at admission. The resident, who was severely cognitively impaired and used a wheelchair, had anxiety listed in their medical record but not in the PASARR document. This was confirmed by a Social Services Designee.
A facility failed to notify the state mental health authority of a significant change in a resident's mental health condition, specifically regarding the PASARR process. The resident, admitted with multiple diagnoses including PTSD, received a new PTSD diagnosis during their stay, but the facility did not complete a significant change PASARR or notify the state mental health authority. The Director of Nursing confirmed the oversight.
Failure to Implement Timely Pressure Ulcer Interventions and RN-Level Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate pressure ulcer interventions and to complete weekly pressure ulcer assessments, including staging, in accordance with professional standards for one resident. The resident was admitted with multiple significant diagnoses, including cerebral infarction, heart failure, neuromuscular bladder dysfunction, weakness, and multiple sclerosis, and was totally dependent for bed mobility, transfers, toilet hygiene, and bathing. The resident had an indwelling catheter, an ostomy, and a documented stage IV pressure ulcer, yet the baseline care plan and activities of daily living plan identified a left buttock pressure ulcer without including preventive measures such as an air mattress, pressure-reducing cushion to the wheelchair, or offloading while in the wheelchair. The Braden Scale score indicated low risk for skin breakdown, and the physician’s admission assessment did not include an assessment of the left buttock pressure ulcer. From admission through early April, weekly skin grid pressure assessments documented a left buttock pressure ulcer that was staged as a stage II ulcer and showed progressive worsening in size and drainage. Measurements increased from 3.5 cm by 4.5 cm by 0.2 cm with minimal serosanguineous drainage to 5.0 cm by 6.0 cm by 1.8 cm with moderate serosanguineous drainage and slight odor. During this period, the resident was transferred from a motorized wheelchair, which had a pressure-reducing cushion, to a standard wheelchair for safety reasons, but there were no corresponding orders or care plan interventions for a pressure-reducing cushion on the standard wheelchair or for an air mattress overlay until early April. The comprehensive care plan initiated for risk of impaired skin integrity initially contained no interventions. The weekly skin grid pressure ulcer assessments were completed by an LPN unit manager who was not wound certified and who reported being unable to stage pressure ulcers within her scope of practice, yet she documented staging on the weekly assessments. There was no documentation in the medical record from admission through early April of communication to an RN or physician regarding the assessment, description, and staging of the left buttock pressure ulcer, and no documented RN or physician assessments of the ulcer during that time. The DON acknowledged that the LPN completed the weekly assessments and that there was no documentation of RN or physician verification of staging or assessment, and confirmed the absence of documented preventive interventions such as an air mattress and pressure-reducing cushion until orders were written in early April. Facility policies required complete, accurate, and objective documentation of assessments and services, and the Ohio Board of Nursing information cited limits on LPN practice, including that LPN care is provided at the direction of an RN, but these standards were not met in this case.
Failure to assess self-administration of topical medication
Penalty
Summary
The facility failed to ensure the Interdisciplinary Team determined whether self-administration of a topical medication was clinically appropriate for one resident. The resident was cognitively intact and had edema, a venous ulcer, cellulitis, malignant neoplasm of skin, and local infection of the skin and subcutaneous tissue. The medical record showed orders for triamcinolone acetonide 0.1% cream to be applied to a rash on both arms and to the left lower extremity every shift, but the orders did not include instructions that the resident could self-apply. The MARs for March and April showed nursing staff signed off that the medication was administered, and the record had no documentation of a medication self-administration assessment or care plan at the time of review. During observation, a tube of triamcinolone cream was found at the resident’s bedside, and the resident stated they were self-applying the cream to a biopsy site on the left hand that was not healing. An LPN later confirmed the resident was self-applying the medication and stated the resident had cancer removed from the left hand and did not have a treatment order to apply triamcinolone to that location. The Regional Quality Assurance Nurse and Regional Director of Operations stated the self-administration assessment was documented in the electronic record, but review showed the assessment was completed only after the issue was brought to the facility’s attention. The facility policy required staff and the practitioner to assess the resident’s mental and physical abilities to determine whether self-administration was clinically appropriate, and required medications found at the bedside that were not authorized for self-administration to be given to the Charge Nurse.
Failure to Develop Tube Feeding Care Plan
Penalty
Summary
The facility failed to develop a plan of care for a resident with a gastrostomy tube who was receiving tube feedings. Resident #07 was admitted with diagnoses including metabolic encephalopathy, diabetes mellitus type II, COPD, depression, atherosclerosis, protein-calorie malnutrition, morbid obesity, hyperlipidemia, chronic pain, sciatica, asthma, cerebral infarction, anxiety, depression, and epilepsy. The quarterly MDS showed minimally impaired cognition. Review of the comprehensive care plan, last revised on 04/19/26, showed no care plan in place to address tube feeding needs when the resident readmitted with a new gastrostomy tube. Physician orders included enteral feeding for dysphagia with Two Cal at 60 ml/hour for 12 hours, starting at 5:00 P.M. and stopping at 5:00 A.M. daily, along with water flushes, placement checks, air bolus checks, and daily site care with soap and water and a new dressing. The MDS Coordinator verified that a tube feeding care plan was not in place on the nutritional care plan until 04/19/26, and that the resident had been receiving tube feedings since 01/12/26.
Incorrectly Transcribed Catheter Order During Voiding Trial
Penalty
Summary
The facility failed to accurately transcribe, clarify, and follow a prescriber’s order for a resident who was on a voiding trial after removal of an indwelling Foley catheter. Resident #06 was admitted with diagnoses including diabetes mellitus, chronic kidney disease stage three, and obstructive and reflux uropathy, and was documented as cognitively intact with an indwelling urinary catheter on admission. The care plan identified an alteration in elimination related to the resident’s conditions and Foley catheter use. A prescriber order dated 03/02/26 directed removal of the catheter for a voiding trial and straight catheterization every eight hours as needed for urinary retention, with the catheter to be left in place if 2400 mL of urine was obtained. After the catheter was discontinued, documentation showed the resident was straight catheterized and 850 mL of urine was obtained, and later a late-entry note documented abdominal pain, abdominal distention, and tenderness with straight catheterization yielding 1400 mL of urine. The note stated the straight catheter was left in place per order. During interview, the DON verified the order reflected 2400 mL, but the DON and NP confirmed the intended threshold was 400 mL, not 2400 mL, and that the order had been transcribed incorrectly and not clarified. Review of the MAR showed straight catheterization documented only once in March, with no other straight catheterization documentation for that month.
Failure to Properly Manage Resident Personal Funds
Penalty
Summary
The facility failed to properly hold, secure, and manage each resident's personal money that was deposited with the nursing home. This deficiency indicates that the required procedures for safeguarding residents' funds were not followed, resulting in improper management of personal monies entrusted to the facility by residents.
Failure to Protect Residents' Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that the facility failed to ensure that each resident was safeguarded against unauthorized or improper use of their personal property or financial resources. Specific details about the actions or inactions that led to this deficiency, as well as information about the residents involved or their medical history, are not provided in the report.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being. No additional details about the specific resident's medical history or condition at the time of the deficiency are provided in the report.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to ensure food was stored and served in a safe and sanitary manner, affecting all 42 residents who received food from the facility kitchen. During an observation of the milk cooler, it was found that two gallons of milk were opened and had an expiration date of 11/30/24, which was past the date of observation on 12/02/24. This was confirmed by a staff member, and it was noted that the facility's food receiving and storage policy required food to be stored in compliance with safe food handling practices. Additionally, the Dietary Manager (DM) was observed serving breakfast without adhering to proper hygiene protocols. The DM wore gloves and had a towel draped on his shoulder, which he used to wipe perspiration from his face and head. Despite having facial hair, the DM did not wear a protective facial hair restraint. The DM was seen placing toast on plates with gloved hands, touching the counter, and wiping his face with the towel without changing gloves or washing hands throughout the meal service. This was in violation of the facility's policy that required food preparation staff to adhere to proper hygiene, including changing gloves between tasks and wearing hair restraints.
Inadequate Food Portions for Special Diets
Penalty
Summary
The facility failed to ensure that residents received food portions according to the menu spreadsheet, affecting 17 residents on mechanical soft or pureed diets out of a census of 42. The menu spreadsheet specified that mechanical soft diets should receive 4 ounces of mechanical roast beef, 2 ounces of gravy, 4 ounces of garlic mashed potatoes, 4 ounces of Normandy vegetable blend, and one slice of wheat bread. Pureed diets were to receive 4 ounces of pureed roast beef, two and two-thirds ounces of pureed Normandy vegetable blend, two-thirds slice of pureed bread, and 4 ounces of mashed potatoes. During an observation of the tray line, it was noted that the Dietary Manager (DM) provided only a 2-ounce scoop of mechanical roast beef and a roll instead of the specified portions for mechanical soft diets. For pureed diets, residents received a 2-ounce scoop of pureed roast beef and a 2-ounce scoop of pureed Normandy vegetable blend, without the pureed bread. The DM confirmed these discrepancies and stated that the gravy was mixed into the mechanical roast beef, which was included in the 2-ounce scoop provided. Additionally, there was no pureed bread available for residents on pureed diets.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to serve food as prescribed for residents on a controlled carbohydrate therapeutic diet, affecting all 15 residents who were supposed to receive this diet. The deficiency was identified through observation, staff interviews, medical record reviews, and policy reviews. Specifically, Resident #8, who had multiple diagnoses including diabetes and was on a controlled carbohydrate diet, was observed receiving regular syrup instead of the prescribed reduced calorie syrup during breakfast. This issue was not isolated to Resident #8, as 14 other residents with similar dietary orders also received regular syrup. Interviews with staff, including a Certified Nurse Aide and Dietary Aides, confirmed that regular syrup was served to all residents on a controlled carbohydrate diet due to a lack of reduced calorie syrup in the facility. The Dietary Manager verified that there had been no recent deliveries of reduced calorie syrup and was unaware of the shortage. The facility's policy on therapeutic diets, which requires adherence to physician orders for dietary modifications, was not followed, leading to the deficiency.
Inaccurate Coding of Non-Invasive Ventilation on MDS
Penalty
Summary
The facility failed to accurately code the status of a non-invasive mechanical ventilation on a resident's Minimum Data Set (MDS) assessments. The resident, who was cognitively intact and used mobility aids, was incorrectly coded as using an invasive mechanical ventilator. This error persisted across multiple MDS assessments from November 2023 to August 2024. The resident had a Beyond ResPlus B-30P BiPAP machine, which is a non-invasive device, at her bedside and confirmed she had never used an invasive ventilator in the facility. The resident's medical history included conditions such as myocardial infarction, depression, atrial fibrillation, and chronic respiratory failure, among others. Physician orders indicated the use of an Average Volume Assured Pressure Support (AVAPS) machine during sleep and as needed for respiratory distress. Despite this, the MDS assessments inaccurately reflected the use of an invasive ventilator, contrary to the resident's actual use of a non-invasive BiPAP machine. Interviews with facility staff, including the MDS Coordinator and Corporate Nurse, confirmed the coding error. The user manual for the BiPAP machine and a government website were reviewed, both indicating that the device was non-invasive. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual provided clear guidelines on coding non-invasive versus invasive mechanical ventilation, which were not followed in this case.
Inaccurate PASARR Documentation for Resident
Penalty
Summary
The facility failed to ensure the accuracy of Preadmission Screening and Resident Review (PASARR) documents for a resident with multiple diagnoses. Specifically, the PASARR document for a resident admitted with a diagnosis of anxiety did not reflect this condition. The resident, who was severely cognitively impaired and used a wheelchair for mobility, had a medical record indicating anxiety at the time of admission. However, the PASARR document dated July 30, 2024, did not list anxiety as a diagnosis. This discrepancy was confirmed during an interview with the Social Services Designee.
Failure to Notify State Mental Health Authority of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify the state mental health authority of a significant change in a resident's mental health condition, specifically regarding the Preadmission Screening and Resident Review (PASARR) process. This deficiency was identified during a review of the medical records and staff interviews, affecting one of the two residents reviewed for PASARR documents. The resident in question was admitted with multiple diagnoses, including congestive heart failure, chronic pulmonary disease, type two diabetes mellitus, PTSD, brief psychotic disorder, adjustment disorder with mixed anxiety and depressed mood, and unspecified dementia with psychotic disturbance. The resident's medical record indicated a new diagnosis of PTSD was added during their stay at the facility, but the facility did not complete a significant change PASARR or notify the state mental health authority of this new diagnosis. The psychiatric note confirmed the new PTSD diagnosis and the prescription of Prazosin for PTSD-related symptoms. The Director of Nursing verified that the facility did not complete the necessary PASARR update or notification to the state mental health authority following the new diagnosis.
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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) |
|---|---|---|---|---|
| Edgewood Manor Of Greenfield | 0.6 mi | ★★★★★ | 2 | 0 |
| Embassy Of Valley View | 9 mi | ★★★★★ | 2 | 0 |
| Vineyards At Concord, The | 11.3 mi | ★★★★★ | 33 | 0 |
| Copper Knoll Health & Rehab Llc | 12.6 mi | ★★★★★ | 13 | 0 |
| Court House Manor | 13.7 mi | ★★★★★ | 0 | 0 |
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