Greenfield Skilled Nursing: Unsafe Discharge - OH
Resident #48 left Greenfield Skilled Nursing and Rehabilitation on May 22 with a discharge plan that listed Ross County Home Health as her care provider. But the agency had already denied the referral twice and never met with the resident or started any services.
The 88-year-old woman scored just 6 out of 15 on a cognitive assessment, indicating significant mental impairment. She required substantial to maximum help with showering, dressing, personal hygiene, rolling over in bed and sitting up. Staff had to provide complete assistance with toileting, getting dressed below the waist, transferring from chairs to beds, and moving from sitting to standing positions.
Walking 10 feet and getting in and out of cars were deemed too dangerous to attempt.
Her insurance coverage was ending. The facility learned on May 14 that she had seven days of coverage remaining, with the last covered day being May 21. The therapy director said the resident had been "cut from therapy" and wanted to go home with family rather than pay privately for continued care.
But the family was reluctant to take her home, according to the therapy director, who felt the resident had pressured them into agreeing to the discharge.
Ross County Home Health had declined to serve her immediately. The agency received the referral on May 22 — the same day she was discharged — and told facility staff that same day they were out of network with her insurance.
When the nursing home didn't respond, the agency sent a second email on June 1 confirming they were still out of network and couldn't provide services. Again, no one from the facility replied.
"They confirmed they had never met with Resident #48 or initiated services," inspectors wrote.
The facility's own staff acknowledged the discharge was unsafe. The director of nursing told inspectors she expected "a safe discharge plan" and that the previous social services staff should have confirmed a home health agency would accept the resident before sending her home.
She also admitted the discharge summary contained false information, stating the resident was leaving because she had "met therapy goals" rather than the actual reason — her insurance coverage had ended.
The director of nursing confirmed the facility "sent Resident #48 home without the needed and recommended services, which was not a safe discharge plan."
Regional Nurse #200 told inspectors the facility had no evidence that any home health agency had accepted the resident at the time of discharge. The facility only sent referrals on May 22, the day she left, with no prior discharge planning documented.
No discharge care conference was held.
When the regional nurse received an email in June about the failed referrals for Resident #48, her response revealed the facility's approach to discharge planning: "it was not our job to ensure the resident had services arranged prior to discharge to ensure a safe discharge plan."
Facility managers told inspectors they had discussed insurance difficulties with the resident and her family, but acknowledged they had no documentation of these conversations or evidence of any discharge planning challenges.
The administrator confirmed the facility knew on May 14 that insurance coverage was ending but waited until the final day to arrange home health services.
The resident's son, who held power of attorney, signed the discharge paperwork and took his mother home believing she would receive the aide services, physical therapy and occupational therapy listed in her discharge plan.
Instead, she went home with none of the substantial daily assistance that staff had determined she required for basic activities like bathing, dressing and moving safely around a home.
The violation occurred during a complaint investigation, suggesting someone reported concerns about how the facility handled the discharge.
Federal regulations require nursing homes to develop comprehensive discharge plans that ensure residents can safely transition to their next level of care. The plans must identify specific services and providers, and facilities must coordinate with those providers before discharge.
Greenfield Skilled Nursing failed on multiple levels: sending referrals only on discharge day, not following up when agencies declined, falsifying the reason for discharge, and sending home a vulnerable resident without confirming any services were in place.
The resident's family was left to care for someone who needed help with nearly every aspect of daily living, believing professional assistance was coming that would never arrive.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greenfield Skilled Nursing and Rehabilitation from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
GREENFIELD SKILLED NURSING AND REHABILITATION in GREENFIELD, OH was cited for violations during a health inspection on August 20, 2025.
Resident #48 left Greenfield Skilled Nursing and Rehabilitation on May 22 with a discharge plan that listed Ross County Home Health as her care provider.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.