Inspection Reports for
Greenfield Health & Rehab Center
5949 Broadway, Lancaster, NY, 14086
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
15.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
208% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Routine
Deficiencies: 4
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.
Deficiencies (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
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Aug 8, 2025
Visit Reason
Inspection identified 7 standard health citations and 4 life safety code citations, including issues with bowel/bladder incontinence, infection control, and fire alarm system maintenance.
Findings
Inspection identified 7 standard health citations and 4 life safety code citations, including issues with bowel/bladder incontinence, infection control, and fire alarm system maintenance.
Deficiencies (11)
Bowel/bladder incontinence, catheter, uti
Department criminal history review
Entering into binding arbitration agreements
Infection control
Parenteral/iv fluids
Responsibilities of providers; required notif
Right to be free from chemical restraints
Fire alarm system - testing and maintenance
Hvac
Means of egress - general
Soiled linen and trash containers
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 18, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of verbal abuse and neglect of Resident #134 and improper use of physical restraints on Resident #113.
Complaint Details
Complaint #NY00324906 involved verbal abuse and neglect of Resident #134, which was substantiated. Complaint #NY00325623 involved improper use of physical restraints on Resident #113, which was unsubstantiated.
Findings
The facility was found to have substantiated verbal abuse and neglect towards Resident #134 by a Certified Nursing Assistant who yelled, swore, and threw the resident's call bell. The facility also failed to ensure residents were free from physical restraints when a wet floor sign was placed behind Resident #113's wheelchair to restrict movement, though this incident was ultimately unsubstantiated.
Deficiencies (2)
F 0600: The facility did not protect Resident #134 from verbal abuse and neglect by a Certified Nursing Assistant who yelled, swore, took the call bell away, and threw it at the wall. The complaint was substantiated based on interviews, call bell logs, and investigation.
F 0604: The facility did not ensure Resident #113 was free from physical restraints when a wet floor sign was placed behind their wheelchair to prevent movement. The incident was investigated and found unsubstantiated as Resident #113 was able to roll over the sign.
Report Facts
Residents Affected: 1
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #11 | Named in verbal abuse and neglect finding involving Resident #134 | |
| Physical Therapist #3 | Reported verbal abuse allegation and interviewed Resident #134 | |
| Director of Social Work and Registered Nurse #5 | Interviewed regarding Resident #134's abuse allegations | |
| Licensed Practical Nurse #7 | Involved in physical restraint incident with Resident #113 and counseled | |
| Licensed Practical Nurse #8 | Interviewed regarding physical restraint incident with Resident #113 |
Inspection Report
Complaint Investigation
Deficiencies: 6
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.
Deficiencies (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
Complaint Investigation
Capacity: 60
Deficiencies: 16
Date: Dec 18, 2023
Visit Reason
Complaint survey with 7 standard health citations and 9 life safety code citations, including antibiotic stewardship, abuse prevention, infection control, privacy, and multiple life safety code issues corrected by early 2024.
Findings
Complaint survey with 7 standard health citations and 9 life safety code citations, including antibiotic stewardship, abuse prevention, infection control, privacy, and multiple life safety code issues corrected by early 2024.
Deficiencies (16)
Antibiotic stewardship program
Free from abuse and neglect
Free of accident hazards/supervision/devices
Infection prevention & control
Personal privacy/confidentiality of records
Responsibilities of providers; required notif
Right to be free from physical restraints
Cooking facilities
Corridor - doors
Electrical systems - essential electric syste
Fire drills
Gas equipment - cylinder and container storag
Hazardous areas - enclosure
Means of egress - general
Soiled linen and trash containers
Sprinkler system - maintenance and testing
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 18, 2023
Visit Reason
Complaint survey with one standard health citation for investigating and preventing alleged violations, corrected by February 2023.
Findings
Complaint survey with one standard health citation for investigating and preventing alleged violations, corrected by February 2023.
Deficiencies (1)
Investigate/prevent/correct alleged violation
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jan 3, 2023
Visit Reason
Complaint survey with two standard health citations including a Level 4 immediate jeopardy for CPR and a Level 2 for notification of changes, both corrected by February 2023.
Findings
Complaint survey with two standard health citations including a Level 4 immediate jeopardy for CPR and a Level 2 for notification of changes, both corrected by February 2023.
Deficiencies (2)
Cardio-pulmonary resuscitation (cpr)
Notify of changes (injury/decline/room, etc.)
Inspection Report
Complaint Investigation
Deficiencies: 1
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.
Deficiencies (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 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: May 31, 2022
Visit Reason
Complaint survey with several standard health citations including criminal history checks, infection control, and reporting of alleged violations, mostly corrected by mid-2022.
Findings
Complaint survey with several standard health citations including criminal history checks, infection control, and reporting of alleged violations, mostly corrected by mid-2022.
Deficiencies (4)
Criminal history record check process
Department criminal history review
Infection control
Reporting of alleged violations
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