Greenfield Health & Rehab Center

Greenfield Health & Rehab Center

5949 Broadway

Lancaster, NY 14086

(716) 684-3000

www.niagaralutheran.org/content/pages/greenfield-rehab

Services: Baseline Services, Respite Care (Short Term), Outpatient/Speech Language Pathology Therapy, Outpatient/Occupational Therapy, Outpatient/Physical Therapy

Beds

Behavioral Intervention:
Pediatric:
Pediatric Ventilator Dependent:
Residential Health Care:160
Transitional Care Unit:
Ventilator Dependent:
Total Number of Beds:160

Administrative

Ownership: Voluntary--Not for Profit Corporation

Operated by: Niagara Lutheran Development Inc
64 Hager Street
Buffalo, NY 14208

Permanent Facility Identifier: 7711

Operating Certificate: 1467301N

Medicaid Certified

Medicare Certified

Medicare Number: 335182

Statistics

Employee Flu Vaccination Rate: 50%

Occupancy Rate: 97%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain3.117146/1/2017
425Percentage of short-stay residents with pressure ulcers that are new or worsened0.694246/1/2017
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine91.938586/1/2017
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine95.614466/1/2017
434Percentage of short-stay residents who newly received an antipsychotic medication1.210826/1/2017
471Percentage of short-stay residents who made improvements in function35.602326/1/2017

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased18.059299006/1/2017
402Percentage of long-stay residents who self-report moderate to severe pain0.551497006/1/2017
403Percentage of high risk long-stay residents with pressure ulcers4.310345006/1/2017
404Percentage of long-stay residents who lose too much weight5.839416006/1/2017
405Percentage of low risk long-stay residents who lose control of their bowels or bladder47.619048006/1/2017
406Percentage of long-stay residents with a catheter inserted and left in their bladder1.567458006/1/2017
407Percentage of long-stay residents with a urinary tract infection1.216545006/1/2017
408Percentage of long-stay residents who have depressive symptoms10.098523006/1/2017
409Percentage of long-stay residents who were physically restrained0.000000006/1/2017
410Percentage of long-stay residents experiencing one or more falls with major injury3.631962006/1/2017
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine99.047619006/1/2017
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine71.428573006/1/2017
419Percentage of long-stay residents who received an antipsychotic medication10.098522006/1/2017
451Percentage of long-stay residents whose ability to move independently worsened31.908043006/1/2017
452Percentage of long-stay residents who received an antianxiety or hypnotic medication15.856777006/1/2017

Complaints

Number of Standard Health Deficiencies:26
Number of Live Safety Code Deficiencies:17
Number of Total Deficiencies:43
Number of Deficiencies related to Actual Harm or Immediate Jeopardy:1
Percent of Total Deficiencies related to Actual Harm or Immediate Jeopardy :2
Total intakes received (last three years):42
Intakes received per 100 occupied beds (last three years):28.1
Percent of total intakes received that were facility self reported incidents (last three years):57
On-site complaint investigations (last three years):15
Complaint investigations resulting in citations (last three years):5
Complaint investigations resulting in citations per 100 occupied beds (last three years):3.3
Complaint Citations in deficiency category: Administration:0
Complaint Citations in deficiency category: Quality of Care:4
Complaint Citations in deficiency category: Resident Rights:1
Complaint Citations in deficiency category: Dietary Services:0
Complaint Citations in deficiency category: Physical Environment:0
Complaint Citations in deficiency category: Other Services:0
Complaint Citations across all deficiency categories (last three years):5

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
1/28/2014Certification2
10/15/2013Complaint2
2/18/2016Certification2
2/6/2015Certification3
2/8/2017Certification2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate citation corrected
HealthFACILITY IS FREE OF ACCIDENT HAZARDS2111/30/2013
HealthSERVICES BY QUALIFIED PERSONS IN ACCORDANCE WITH CARE PLAN2111/30/2013
LSCDOORS IN SMOKE PARTITIONS223/11/2016
LSCSMOKE PARTITION CONSTRUCTION223/11/2016
LSCEXIT ACCESS223/11/2016
LSCEMERGENCY PLAN223/11/2016
HealthSTANDARDS OF CONSTRUCTION FOR NEW NURSING HOME133/11/2016
LSCSPRINKLER SYSTEM MAINTENANCE233/21/2014
LSCAUTOMATIC SPRINKLER SYSTEM223/21/2014
LSCMEDICAL GAS SYSTEM223/21/2014
LSCSMOKE PARTITION CONSTRUCTION223/21/2014
LSCHAZARDOUS AREAS - SEPARATION223/21/2014
HealthRESIDENT DRUG REGIMEN REVIEWED MONTHLY BY PHARMACIST213/21/2014
LSCSTAIRWAY ENCLOSURES AND VERTICAL SHAFTS223/21/2014
HealthFACILITY IS FREE OF ACCIDENT HAZARDS213/21/2014
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS213/21/2014
HealthRESIDENT NOT CATHETERIZED UNLESS UNAVOIDABLE213/21/2014
LSCEXIT ACCESS223/21/2014
HealthSTORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS213/21/2016
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS213/24/2017
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING213/24/2017
HealthFACILITY ESTABLISHES INFECTION CONTROL PROGRAM223/24/2017
HealthINFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.213/24/2017
LSCSPRINKLER SYSTEM MAINTENANCE223/25/2016
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS214/18/2016
HealthINFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.214/18/2016
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES214/18/2016
LSCHAZARDOUS AREAS - SEPARATION224/6/2015
HealthRESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS224/6/2015
LSCTESTING OF FIRE ALARM224/6/2015
HealthSELF-DETERMINATION - RESIDENT MAKES CHOICES214/6/2015
HealthCOMFORTABLE AND SAFE TEMPERATURE LEVELS214/6/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS214/6/2015
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING214/6/2015
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES214/6/2015
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS224/6/2015
HealthRESIDENT DRUG REGIMEN REVIEWED MONTHLY BY PHARMACIST224/6/2015
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS214/6/2015
LSCEXIT ACCESS224/6/2015
LSCMEDICAL GAS SYSTEM224/6/2015
LSCGENERATORS INSPECTED/TESTED224/6/2015
HealthSTORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS214/6/2015