Inspection Reports for
Greenfield Health & Rehab Center
5949 Broadway, Lancaster, NY, 14086
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Inspection Report — Feb 25, 2026
Complaint Investigation State
Date: Feb 25, 2026
Visit Reason
State-compiled facility profile showing 12 inspections from 2022 to 2026 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 132 complaints about this facility; 27 led to on-site inspections. The facility received 87.7 complaints per 100 beds versus a statewide rate of 57.4, resulting in 6 citations from those complaints.
Findings
Across 12 inspections, 7 had no citations and 5 resulted in 31 total citations including standard health and life safety code violations. The facility had 132 complaints with 27 on-site inspections and 3 enforcement actions totaling $20,000 in fines.
Citations (31)
Standard Health Citation — quality of care: Reporting Of Alleged Violations not properly conducted.
Standard Health Citation — quality of care: Bowel/bladder Incontinence, Catheter, Uti issues identified.
Standard Health Citation — quality of care: Department Criminal History Review deficiencies noted.
Standard Health Citation — quality of care: Entering Into Binding Arbitration Agreements improperly handled.
Standard Health Citation — quality of care: Infection Control deficiencies found.
Standard Health Citation — quality of care: Parenteral/iv Fluids issues identified.
Standard Health Citation — quality of care: Responsibilities Of Providers; Required Notifications not met.
Standard Health Citation — quality of care: Right To Be Free From Chemical Restraints violated.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance deficiencies.
Life Safety Code Citation — NFPA requirements: HVAC system issues found.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General problems noted.
Life Safety Code Citation — NFPA requirements: Soiled Linen And Trash Containers improperly managed.
Standard Health Citation — quality of care: Antibiotic Stewardship Program deficiencies.
Standard Health Citation — quality of care: Free From Abuse And Neglect violations.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices issues.
Standard Health Citation — quality of care: Infection Prevention & Control deficiencies.
Standard Health Citation — quality of care: Personal Privacy/confidentiality Of Records not maintained.
Standard Health Citation — quality of care: Responsibilities Of Providers; Required Notifications not met.
Standard Health Citation — quality of care: Right To Be Free From Physical Restraints violated.
Life Safety Code Citation — NFPA requirements: Cooking Facilities deficiencies noted.
Life Safety Code Citation — NFPA requirements: Corridor - Doors issues found.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System problems.
Life Safety Code Citation — NFPA requirements: Fire Drills deficiencies.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storage issues.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure problems.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General problems noted.
Life Safety Code Citation — NFPA requirements: Soiled Linen And Trash Containers improperly managed.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficiencies.
Standard Health Citation — quality of care: Investigate/prevent/correct Alleged Violation not properly conducted.
Standard Health Citation — quality of care: Cardio-pulmonary Resuscitation (CPR) deficiencies.
Standard Health Citation — quality of care: Notify Of Changes (injury/decline/room, Etc.) failures.
Report Facts
Inspections on page: 12
Total citations: 31
Inspections with no citations: 7
Inspections with citations: 5
Total complaints: 132
On-site complaint inspections: 27
Citations from complaints: 6
Enforcement actions: 3
Total fines: 20000
Inspection Report — Aug 8, 2025
Routine CMS
Date: Aug 8, 2025
Visit Reason
The inspection was a standard routine survey conducted to assess compliance with regulatory requirements related to medication use, catheter care, intravenous therapy, and resident rights.
Findings
The facility was found deficient in ensuring residents were free from unnecessary psychotropic medications, providing appropriate catheter care including use of leg bags, administering intravenous antibiotics timely and maintaining central venous catheter care, and properly informing residents about binding arbitration agreements with correct rescission periods.
Citations (4)
F 0605: The facility increased Resident #157's Xanax dose without documented clinical indication or medical provider order, resulting in unnecessary psychotropic medication use.
F 0690: Resident #113 with an indwelling catheter was not consistently provided a urinary leg bag as preferred, and catheter drainage tubing was observed touching the floor, posing infection control risks.
F 0694: Resident #174 did not receive intravenous antibiotics timely per hospital discharge orders, and there were no physician orders for central venous catheter maintenance, causing delays and risk of catheter occlusion.
F 0847: The facility's Binding Arbitration Agreement allowed only seven days for residents to rescind the agreement, contrary to regulatory requirements for a 30-day rescission period.
Report Facts
Residents reviewed for psychotropic medication: 5
Residents reviewed for catheter care: 3
Resident reviewed for IV therapy: 1
Days delay in IV antibiotic administration: 2
Days allowed to rescind arbitration agreement per facility: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician Assistant #2 | Psychiatry Physician Assistant | Named in medication error finding related to Resident #157's Xanax dosage increase. |
| Nurse Practitioner #1 | Nurse Practitioner | Named in medication error finding and IV therapy deficiency related to Resident #157 and Resident #174. |
| Registered Nurse #9 | Unit Manager | Named in medication error finding related to transcription error of Resident #157's Xanax order. |
| Director of Nursing | Director of Nursing | Provided statements regarding medication and catheter care deficiencies. |
| Pharmacy Consultant | Pharmacy Consultant | Participated in review of psychotropic medication and IV therapy deficiencies. |
| Director of Admissions | Director of Admissions | Named in arbitration agreement deficiency related to rescission period explanation. |
| Licensed Practical Nurse #4 | Nursing Supervisor | Initiated maintenance orders for Resident #174's central venous catheter. |
Inspection Report — Dec 18, 2023
Complaint Investigation CMS
Date: Dec 18, 2023
Visit Reason
The survey was conducted as a complaint investigation based on allegations of privacy violations, abuse, neglect, improper use of restraints, inadequate supervision, infection control failures, and antibiotic stewardship concerns at the facility.
Complaint Details
The complaint investigation included allegations of privacy violations during podiatry treatment, verbal abuse and neglect by staff, improper use of physical restraints, inadequate supervision leading to a resident fall, failure to follow infection control precautions for COVID-19 positive residents, and failure to monitor antibiotic use appropriately. The complaint was substantiated in multiple areas including abuse and neglect of Resident #134 and improper restraint use on Resident #113.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy during podiatry treatment, substantiated verbal abuse and neglect of a resident by staff, improper use of physical restraints, inadequate supervision leading to a resident fall, failure to implement proper infection control precautions for COVID-19 positive residents, and lack of an effective antibiotic stewardship program with inadequate monitoring of prophylactic antibiotic use.
Citations (6)
F 0583: The facility failed to ensure resident privacy during podiatry treatment when care was provided in a common area without privacy for Resident #62.
F 0600: The facility did not protect Resident #134 from verbal abuse and neglect by Certified Nursing Assistant #11 who yelled, swore, and threw the resident's call light at the wall.
F 0604: The facility failed to ensure Resident #113 was free from physical restraints when a wet floor sign was placed behind their wheelchair to prevent movement.
F 0689: The facility did not provide adequate supervision and failed to use a rolling walker as required for Resident #15, resulting in a fall and injury.
F 0880: The facility failed to maintain an effective infection prevention and control program, as staff did not wear appropriate personal protective equipment including N95 masks when entering COVID-19 positive residents' rooms.
F 0881: The facility did not implement an antibiotic stewardship program that included monitoring and tracking of prophylactic antibiotic use for Resident #131, with no documented rationale or monitoring for continued use.
Report Facts
Deficiencies cited: 6
Resident count for findings: 6
Antibiotic doses and dates: Resident #131 received multiple antibiotics including Macrodantin 50 mg daily starting 5/27/23 with no stop date.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #11 | Named in verbal abuse and neglect finding involving Resident #134. | |
| Licensed Practical Nurse #7 | Named in restraint use finding involving Resident #113. | |
| Licensed Practical Nurse #4 | Named in infection control finding for failure to wear N95 mask entering Resident #116 and #31 rooms. | |
| Resident Aide #1 | Named in infection control finding for failure to wear appropriate PPE entering Resident #95 room. | |
| Registered Nurse/Assistant Director of Nursing/Infection Preventionist | Named in antibiotic stewardship and infection control findings. | |
| Nurse Practitioner #1 | Named in antibiotic stewardship finding regarding prophylactic antibiotic use for Resident #131. | |
| Medical Doctor #2 | Named in antibiotic stewardship finding regarding documentation and rationale for prophylactic antibiotic use. | |
| Consultant Pharmacist #1 | Named in antibiotic stewardship finding regarding monitoring and risks of prophylactic antibiotic use. |
Inspection Report — May 31, 2022
Complaint Investigation CMS
Date: May 31, 2022
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #NY00274853) regarding the facility's failure to timely report alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin, to the appropriate authorities.
Complaint Details
Complaint #NY00274853 involved allegations that the facility failed to timely report incidents of resident-to-resident abuse and injury of unknown origin. The complaint was substantiated by the investigation findings.
Findings
The facility failed to report four resident-to-resident altercations and an injury of unknown origin within the required two-hour timeframe to the New York State Department of Health. Interviews revealed that the facility followed outdated reporting guidance and was unaware of current requirements, resulting in delayed reporting of incidents involving residents #16, 22, 60, and 109.
Citations (1)
F 0609: The facility did not ensure timely reporting of suspected abuse, neglect, or theft to proper authorities. Four residents involved in altercations and an injury of unknown origin were not reported within the required two-hour timeframe.
Report Facts
Residents affected: 4
Date survey completed: May 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse, Supervisor | Reported resident-to-resident altercation to Director of Nursing immediately after incident |
| RN #2 | Unit Coordinator | Unable to recall reporting bruise of unknown origin to DON or reviewing incident report |
| DON | Director of Nursing | Conducted investigation and acknowledged delayed reporting due to outdated guidance |
| Administrator | Responsible for reporting incidents to DOH; acknowledged following outdated reporting manual | |
| LPN #3 | Licensed Practical Nurse | Witnessed resident-to-resident altercation and notified Nursing Supervisor |
| LPN #4 | Supervisor | Notified DON immediately after incidents and assessed residents |
| LPN #5 | Unit Coordinator | Aware of resident-to-resident altercation discussed at morning meeting |
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