Greenfield Health & Rehab Center

Greenfield Health & Rehab Center

5949 Broadway

Lancaster, NY 14086

7166843000

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

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

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: 71%

Occupancy Rate: 85%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain1.86002/1/2019
425Percentage of short-stay residents with pressure ulcers that are new or worsened0.55002/1/2019
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine79.63002/1/2019
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine99.50002/1/2019
434Percentage of short-stay residents who newly received an antipsychotic medication0.43002/1/2019
471Percentage of short-stay residents who made improvements in function74.64002/1/2019

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased19.70002/1/2019
402Percentage of long-stay residents who self-report moderate to severe pain0.00002/1/2019
403Percentage of high risk long-stay residents with pressure ulcers3.17002/1/2019
404Percentage of long-stay residents who lose too much weight5.74002/1/2019
405Percentage of low risk long-stay residents who lose control of their bowels or bladder61.31002/1/2019
406Percentage of long-stay residents with a catheter inserted and left in their bladder0.00002/1/2019
407Percentage of long-stay residents with a urinary tract infection0.24002/1/2019
408Percentage of long-stay residents who have depressive symptoms2.42002/1/2019
409Percentage of long-stay residents who were physically restrained0.00002/1/2019
410Percentage of long-stay residents experiencing one or more falls with major injury4.51002/1/2019
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine96.67002/1/2019
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine99.76002/1/2019
419Percentage of long-stay residents who received an antipsychotic medication11.64002/1/2019
451Percentage of long-stay residents whose ability to move independently worsened17.42002/1/2019
452Percentage of long-stay residents who received an antianxiety or hypnotic medication9.41002/1/2019

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):37
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):54
On-site complaint investigations (last three years):12
Complaint investigations resulting in citations (last three years):3
Complaint investigations resulting in citations per 100 occupied beds (last three years):2.2
Complaint Citations in deficiency category: Administration:0
Complaint Citations in deficiency category: Quality of Care:2
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):3

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
2/18/2016CERTIFICATION/COMPLAINT2
2/6/2015CERTIFICATION/COMPLAINT2
2/8/2017CERTIFICATION/COMPLAINT2
5/18/2018CERTIFICATION/COMPLAINT2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate of Initial SurveyDate Citation Corrected
HealthSTANDARDS OF CONSTRUCTION FOR NEW NH132/18/20163/11/2016
LSCLIFE SAFETY CODE STANDARD222/18/20163/11/2016
LSCLIFE SAFETY CODE STANDARD222/18/20163/11/2016
LSCLIFE SAFETY CODE STANDARD222/18/20163/11/2016
LSCLIFE SAFETY CODE STANDARD222/18/20163/11/2016
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY212/18/20163/21/2016
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
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING212/8/20173/24/2017
LSCLIFE SAFETY CODE STANDARD222/18/20163/25/2016
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS212/18/20164/18/2016
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)212/18/20164/18/2016
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES212/18/20164/18/2016
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES212/6/20154/6/2015
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
HealthCOMFORTABLE & SAFE TEMPERATURE LEVELS212/6/20154/6/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS212/6/20154/6/2015
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS222/6/20154/6/2015
HealthDRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON222/6/20154/6/2015
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY212/6/20154/6/2015
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING212/6/20154/6/2015
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE212/6/20154/6/2015
HealthRESIDENTS FREE OF SIGNIFICANT MED ERRORS222/6/20154/6/2015
HealthSELF-DETERMINATION - RIGHT TO MAKE CHOICES212/6/20154/6/2015
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS215/18/20187/13/2018
HealthCARE PLAN TIMING AND REVISION125/18/20187/13/2018
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES215/18/20187/13/2018
HealthINVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION215/18/20187/13/2018
HealthRESIDENT RECORDS - IDENTIFIABLE INFORMATION215/18/20187/13/2018
LSCGAS EQUIPMENT - CYLINDER AND CONTAINER STORAG225/18/20187/13/2018
LSCEP TRAINING PROGRAM135/18/20187/13/2018
LSCGAS AND VACUUM PIPED SYSTEMS - MAINTENANCE PR225/18/20187/13/2018
LSCEP PROGRAM PATIENT POPULATION135/18/20187/13/2018