Greenfield Health & Rehab Center

Greenfield Health & Rehab Center

5949 Broadway

Lancaster, NY 14086

7166843000

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

Services: Respite Care (Short Term), Baseline Services, Outpatient/Occupational Therapy, Outpatient/Physical Therapy, Outpatient/Speech Language Pathology 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: 55%

Occupancy Rate: 95.6%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain1.22007/1/2018
425Percentage of short-stay residents with pressure ulcers that are new or worsened0.43007/1/2018
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine85.74007/1/2018
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine99.45007/1/2018
434Percentage of short-stay residents who newly received an antipsychotic medication0.71007/1/2018
471Percentage of short-stay residents who made improvements in function81.67007/1/2018

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased18.89007/1/2018
402Percentage of long-stay residents who self-report moderate to severe pain0.00007/1/2018
403Percentage of high risk long-stay residents with pressure ulcers3.70007/1/2018
404Percentage of long-stay residents who lose too much weight4.25007/1/2018
405Percentage of low risk long-stay residents who lose control of their bowels or bladder61.49007/1/2018
406Percentage of long-stay residents with a catheter inserted and left in their bladder0.00007/1/2018
407Percentage of long-stay residents with a urinary tract infection0.24007/1/2018
408Percentage of long-stay residents who have depressive symptoms4.50007/1/2018
409Percentage of long-stay residents who were physically restrained0.00007/1/2018
410Percentage of long-stay residents experiencing one or more falls with major injury3.51007/1/2018
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine95.56007/1/2018
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine99.77007/1/2018
419Percentage of long-stay residents who received an antipsychotic medication10.77007/1/2018
451Percentage of long-stay residents whose ability to move independently worsened14.38007/1/2018
452Percentage of long-stay residents who received an antianxiety or hypnotic medication11.35007/1/2018

Complaints

Number of Standard Health Deficiencies:24
Number of Live Safety Code Deficiencies:14
Number of Total Deficiencies:38
Number of Deficiencies related to Actual Harm or Immediate Jeopardy:0
Percent of Total Deficiencies related to Actual Harm or Immediate Jeopardy :0
Total intakes received (last three years):40
Intakes received per 100 occupied beds (last three years):27.2
Percent of total intakes received that were facility self reported incidents (last three years):60
On-site complaint investigations (last three years):13
Complaint investigations resulting in citations (last three years):2
Complaint investigations resulting in citations per 100 occupied beds (last three years):1.4
Complaint Citations in deficiency category: Administration:0
Complaint Citations in deficiency category: Quality of Care:1
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):2

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
2/18/2016Certification2
2/6/2015Certification3
2/8/2017Certification2
5/18/2018Certification1

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate of Initial SurveyDate Citation Corrected
HealthFree of Accident Hazards/Supervision/Devices215/18/2018
LSCEP Training Program135/18/2018
HealthInvestigate/Prevent/Correct Alleged Violation215/18/2018
HealthCare Plan Timing and Revision125/18/2018
HealthADL Care Provided for Dependent Residents215/18/2018
LSCGas Equipment - Cylinder and Container Storag225/18/2018
LSCGas and Vacuum Piped Systems - Maintenance Pr225/18/2018
HealthResident Records - Identifiable Information215/18/2018
LSCEP Program Patient Population135/18/2018
LSCLIFE SAFETY CODE STANDARD222/18/20163/11/2016
LSCLIFE SAFETY CODE STANDARD222/18/20163/11/2016
LSCLIFE SAFETY CODE STANDARD222/18/20163/11/2016
LSCLIFE SAFETY CODE STANDARD222/18/20163/11/2016
HealthStandards of Construction for New NH132/18/20163/11/2016
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY212/18/20163/21/2016
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING212/8/20173/24/2017
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS212/8/20173/24/2017
HealthINFECTION CONTROL, PREVENT SPREAD, LINENS222/8/20173/24/2017
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)212/8/20173/24/2017
LSCLIFE SAFETY CODE STANDARD222/18/20163/25/2016
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)212/18/20164/18/2016
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES212/18/20164/18/2016
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS212/18/20164/18/2016
HealthSELF-DETERMINATION - RIGHT TO MAKE CHOICES212/6/20154/6/2015
HealthCOMFORTABLE & SAFE TEMPERATURE LEVELS212/6/20154/6/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS212/6/20154/6/2015
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING212/6/20154/6/2015
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES212/6/20154/6/2015
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS222/6/20154/6/2015
HealthRESIDENTS FREE OF SIGNIFICANT MED ERRORS222/6/20154/6/2015
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY212/6/20154/6/2015
HealthDRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON222/6/20154/6/2015
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE212/6/20154/6/2015
LSCLIFE SAFETY CODE STANDARD222/6/20154/6/2015
LSCLIFE SAFETY CODE STANDARD222/6/20154/6/2015
LSCLIFE SAFETY CODE STANDARD222/6/20154/6/2015
LSCLIFE SAFETY CODE STANDARD222/6/20154/6/2015
LSCLIFE SAFETY CODE STANDARD222/6/20154/6/2015