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: 50%

Occupancy Rate: 94%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain3.55110/1/2017
425Percentage of short-stay residents with pressure ulcers that are new or worsened0.54910/1/2017
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine90.5039999999999910/1/2017
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine97.82210/1/2017
434Percentage of short-stay residents who newly received an antipsychotic medication0.3110/1/2017
471Percentage of short-stay residents who made improvements in function53.45800000000000610/1/2017

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased17.7215000010/1/2017
402Percentage of long-stay residents who self-report moderate to severe pain0.0000000010/1/2017
403Percentage of high risk long-stay residents with pressure ulcers4.2980000010/1/2017
404Percentage of long-stay residents who lose too much weight5.7737000010/1/2017
405Percentage of low risk long-stay residents who lose control of their bowels or bladder54.0323000010/1/2017
406Percentage of long-stay residents with a catheter inserted and left in their bladder0.1841000010/1/2017
407Percentage of long-stay residents with a urinary tract infection1.3857000010/1/2017
408Percentage of long-stay residents who have depressive symptoms7.9812000010/1/2017
409Percentage of long-stay residents who were physically restrained0.0000000010/1/2017
410Percentage of long-stay residents experiencing one or more falls with major injury3.6866000010/1/2017
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine96.9027000010/1/2017
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine86.6359000010/1/2017
419Percentage of long-stay residents who received an antipsychotic medication12.0650000010/1/2017
451Percentage of long-stay residents whose ability to move independently worsened16.3695000010/1/2017
452Percentage of long-stay residents who received an antianxiety or hypnotic medication14.3885000010/1/2017

Complaints

Number of Standard Health Deficiencies:25
Number of Live Safety Code Deficiencies:17
Number of Total Deficiencies:42
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):26.7
Percent of total intakes received that were facility self reported incidents (last three years):63
On-site complaint investigations (last three years):11
Complaint investigations resulting in citations (last three years):4
Complaint investigations resulting in citations per 100 occupied beds (last three years):2.7
Complaint Citations in deficiency category: Administration:0
Complaint Citations in deficiency category: Quality of Care:3
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):4

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
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES2111/30/2013
HealthSERVICES BY QUALIFIED PERSONS/PER CARE PLAN2111/30/2013
LSCLIFE SAFETY CODE STANDARD223/11/2016
LSCLIFE SAFETY CODE STANDARD223/11/2016
LSCLIFE SAFETY CODE STANDARD223/11/2016
LSCLIFE SAFETY CODE STANDARD223/11/2016
HealthStandards of Construction for New NH133/11/2016
LSCLIFE SAFETY CODE STANDARD223/21/2014
LSCLIFE SAFETY CODE STANDARD223/21/2014
LSCLIFE SAFETY CODE STANDARD223/21/2014
LSCLIFE SAFETY CODE STANDARD223/21/2014
LSCLIFE SAFETY CODE STANDARD223/21/2014
LSCLIFE SAFETY CODE STANDARD233/21/2014
LSCLIFE SAFETY CODE STANDARD223/21/2014
HealthNO CATHETER, PREVENT UTI, RESTORE BLADDER213/21/2014
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES213/21/2014
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS213/21/2014
HealthDRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON213/21/2014
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY213/21/2016
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS213/24/2017
HealthINFECTION CONTROL, PREVENT SPREAD, LINENS223/24/2017
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)213/24/2017
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING213/24/2017
LSCLIFE SAFETY CODE STANDARD223/25/2016
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS214/18/2016
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES214/18/2016
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)214/18/2016
HealthSELF-DETERMINATION - RIGHT TO MAKE CHOICES214/6/2015
HealthCOMFORTABLE & SAFE TEMPERATURE LEVELS214/6/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS214/6/2015
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING214/6/2015
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES214/6/2015
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS224/6/2015
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY214/6/2015
HealthDRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON224/6/2015
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE214/6/2015
LSCLIFE SAFETY CODE STANDARD224/6/2015
HealthRESIDENTS FREE OF SIGNIFICANT MED ERRORS224/6/2015
LSCLIFE SAFETY CODE STANDARD224/6/2015
LSCLIFE SAFETY CODE STANDARD224/6/2015
LSCLIFE SAFETY CODE STANDARD224/6/2015
LSCLIFE SAFETY CODE STANDARD224/6/2015