Pennsylvania Department of Health
GREENFIELD HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GREENFIELD HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  150 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
GREENFIELD HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on April 3,2024, it was determined that Greenfield Healthcare and Rehabilitation was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:

Based on review of clinical records, facility policy, and facility documentation, and staff interview it was determined that the facility failed to maintain complete and accurate documentation as related to meal intake, medication administration records (MAR), and/or completion of treatment administration records (TAR) for six of six residents reviewed (Residents R2, R3, R4, R7, R8, and R9).

Findings include:

Review of facility policy dated 1/1/24, entitled "Charting and Documentation" indicated that any services provided to the resident shall be documented in the resident's medical record.

Review of Resident R2's clinical record revealed an admission date of 12/7/17, with diagnoses that included dementia (a condition that affects the brains' ability to think, remember things, and function), stroke, and high blood pressure.

Resident R2's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 17 (2/27/24, 2/28/24, 3/1/24, 3/2/24, 3/3/24, 3/4/24, 3/5/34, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, 3/13/24, 3/17/24, 3/23/24, and 3/25/24) of 30 breakfast meals in the past 30 days.

Resident R2's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 18 (2/27/24, 2/28/24, 3/1/24, 3/2/24, 3/3/24, 3/4/24, 3/5/34, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, 3/13/24, 3/17/24, 3/19/24, 3/23/24, and 3/25/24) of 30 lunch meals in the past 30 days.

Resident R2's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on 22 (2/27/24, 2/28/24, 3/1/24, 3/2/24, 3/3/24, 3/4/24, 3/5/34, 3/6/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, 3/13/24, 3/15/24, 3/16/24, 3/18/24, 3/21/24, 3/22/24, 3/24/24, and 3/26/24) of 30 supper meals in the past 30 days.

Resident R2's March 2024 TAR lacked documentation indicating that all ordered treatments were completed as ordered on five different dates on day shift (3/5/24, 3/7/24, 3/10/24, 3/11/24, and 3/12/24) and three different dates on evening shift (3/5/24, 3/7/24, and 3/11/24).


Review of Resident R3's clinical record revealed an admission date of 5/12/21, with diagnoses that included emphysema (a lung disease that results in difficulty breathing), high blood pressure, and anxiety.

Resident R3's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 11 (3/1/24, 3/2/24, 3/3/24, 3/4/24, 3/7/24, 3/8/24, 3/12/24, 3/16/24, 3/17/24, 3/21/24, and 3/22/24) of 30 breakfast meals in the past 30 days.

Resident R3's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 11 (3/1/24, 3/2/24, 3/3/24, 3/4/24, 3/7/24, 3/8/24, 3/12/24, 3/16/24, 3/17/24, 3/21/24, and 3/22/24) of 30 lunch meals in the past 30 days.

Resident R3's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on 17 (2/28/24, 2/29/24, 3/1/24, 3/2/24, 3/4/24, 3/5/24, 3/6/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, 3/14/24, 3/15/24, 3/17/24, and 3/21/24) of 30 supper meals in the past 30 days.

Resident R3's March 2024 TAR lacked documentation indicating that all ordered treatments were completed as ordered on seven different dates on evening shift (3/5/24, 3/7/24, 3/10/24, 3/11/24, 3/12/24, 3/25/24, and 3/26/24) and seven different dates on night shift (3/5/24, 3/7/24, 3/11/24, 3/15/24, 3/18/24, 3/25/24, and 3/26/24).


Review of Resident R4's clinical record revealed an admission date of 1/25/19, with diagnoses that included congestive heart failure (CHF - progressive heart disease that the pumping action of the heart resulting in tiredness and difficulty breathing), high blood pressure, and depression.

Resident R4's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 14 (2/29/24, 3/1/24, 3/2/24, 3/3/24, 3/4/24, 3/5/24, 3/6/24, 3/8/24, 3/11/24, 3/12/24, 3/16/24, 3/17/24, 3/23/24, and 3/24/24) of 30 breakfast meals in the past 30 days.

Resident R4's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 15 (2/28/24, 2/29/24, 3/1/24, 3/2/24, 3/3/24, 3/4/24, 3/5/24, 3/6/24, 3/8/24, 3/11/24, 3/12/24, 3/16/24, 3/17/24, 3/23/24, and 3/24/24) of 30 lunch meals in the past 30 days.

Resident R4's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on 21 (2/27/24, 2/28/24, 3/2/24, 3/3/24, 3/4/24, 3/5/24, 3/6/24, 3/7/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, 3/13/24, 3/14/24, 3/15/24, 3/16/24, 3/17/24, 3/20/24, 3/21/24, 3/23/24, and 3/24/24) of 30 supper meals in the past 30 days.

Resident R4's March 2024 MAR lacked documentation indicating that all ordered medications were administered as ordered one time on night shift (3/10/24).


Resident R7's clinical record revealed an admission date of 10/29/22, with diagnoses that included dementia, high blood pressures, and seizures.

Resident R7's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 13 (2/29/24, 3/1/24, 3/2/24, 3/3/24, 3/4/24, 3/5/24, 3/6/24, 3/8/24, 3/11/24, 3/12/24, 3/16/24, 3/17/24, and 3/25/24) of 30 breakfast meals in the past 30 days.

Resident R7's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 14 (2/28/24, 2/29/24, 3/1/24, 3/2/24, 3/3/24, 3/4/24, 3/5/24, 3/6/24, 3/8/24, 3/11/24, 3/12/24, 3/16/24, 3/17/24, and 3/25/24) of 30 lunch meals in the past 30 days.

Resident R7's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on 20 (2/28/24, 3/2/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, 3/13/24, 3/14/24, 3/15/24, 3/16/24, 3/17/24, 3/18/24, 3/20/24, 3/21/24, 3/23/24, and 3/24/24) of 30 supper meals in the past 30 days.

Resident R7's March 2024 TAR lacked documentation indicating that all ordered treatments were completed as ordered on one date on day shift (3/10/24), two dates on evening shift (3/15/24, and 3/19/24), and seven dates on night shift (3/5/24, 3/6/25, 3/13/24, 3/15/24, 3/18/24, 3/19/24, and 3/25/24).


Review of Resident R8's clinical record revealed an admission date of 9/12/17, with diagnoses that included diabetes, high blood pressure, and dementia.

Resident R8's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 11 ( 2/28/24, 2/29/24 3/4/24, 3/6/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, and 3/18/24) of 30 breakfast meals in the past 30 days.

Resident R8's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 12 (2/28/24, 2/29/24, 3/1/24, 3/4/24, 3/6/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, and 3/18/24) of 30 lunch meals in the past 30 days.

Resident R8's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on 12 (2/29/24, 3/2/24, 3/3/24, 3/4/24, 3/5/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, 3/13/24, 3/16/24, and 3/17/24) of 30 supper meals in the past 30 days.

Resident R8's March 2024 TAR lacked documentation indicating that all ordered treatments were completed as ordered on two different dates on day shift (3/2/24, and 3/24/24) and two different dates on night shift (3/1/24, and 3/17/24).


Review of Resident R9's clinical record revealed an admission date of 12/28/23, with diagnoses that included CHF, Gastro-esophageal reflux disease (GERD - digestive disorder that occurs when stomach acid flows back into the esophagus [tube that carries food from the throat to the stomach]), and constipation.

Resident R9's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 12 (2/27/24, 2/28/24, 3/1/24, 3/6/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/18/24, 3/19/24, and 3/20/24) of 30 breakfast meals in the past 30 days.

Resident R9's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 12 (2/27/24, 2/28/24, 3/1/24, 3/6/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/18/24, 3/19/24, and 3/20/24) of 30 lunch meals in the past 30 days.

Resident R9's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on 8 (3/9/24, 3/10/24, 3/11/24, 3/12/24, 3/13/24, 3/19/24, 3/20/24, and 3/24/24) of 30 supper meals in the past 30 days.

Resident R9's March 2024 TAR lacked documentation indicating that all ordered treatments were completed as ordered on two dates on day shift (3/1/24, and 3/24/24), and one date on night shift (3/1/24).

During an interview on 3/27/24, at 5:52 p.m. the Director of Nursing confirmed that Residents R2, R3, R4, R7, R8, and R9 lacked documentation regarding their meal intake in the last thirty days, completion of MAR, and or completion of TAR for March 2024.

28 Pa. Code 211.5(f)(ii)(ix) Medical records

28 Pa. Code 211.12(d)(1)(5) Nursing services




 Plan of Correction - To be completed: 04/15/2024

For Resident R2, R3, R4, R7, R8, R9 and all residents of the facility the following will be implemented to ensure that documentation for resident meal consumption will occur:
Nursing staff will be educated on documentation of meal consumption by the Assistant Director of Nursing or designee.
10% of residents will be audited for complete and accurate documentation. This audit will be conducted by the Assistant Director of Nursing or designee 3 times a week for 2 weeks, 2 times a week for 2 weeks and then weekly ongoing including off shifts to ensure that meal consumption is recorded for residents. This audit will be monitored by the Director of Nursing.
Findings will be reported to the QAPI committee for review and recommendations.

For Resident R2, R3, R7, R8, R9 and all residents of the facility the following will occur to ensure that documentation for all ordered treatments is completed as ordered:
Licensed nursing staff to be educated on documentation for ordered treatments by the Assistant Director of Nursing or designee
10% of residents will be audited for complete and accurate documentation. This audit will be conducted by the Assistant Director of Nursing or designee 3 times a week for 2 weeks, 2 times a week for 2 weeks and then weekly ongoing including off shifts to ensure that documentation for all ordered treatments is completed.
Findings will be reported to the QAPI committee for review and recommendations.

For Resident R4 and all residents of the facility the following will be implemented to ensure that documentation for all medications are administered as ordered:
Licensed nursing staff to be educated on documentation medication administered as ordered by the Director of Nursing or designee
10% of residents will be audited for complete and accurate documentation.
This audit will be conducted by the Director of Nursing or designee 3 times a week for 2 weeks, 2 times a week for 2 weeks and then weekly ongoing to ensure that documentation for all medication are administered as ordered.
Findings will be reported to the QAPI committee for review and recommendations.



Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port