Cycle 1
Health 2025-08-08 · Fire 2025-08-08
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Lancaster, NY
Greenfield Health & Rehab Center
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
5949 Broadway, Lancaster, NY
(716) 684-3000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
155
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.67
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.39
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.70
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.77
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
2.06
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.95
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.26
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
5.16
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,388
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9977
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.62
Baseline 21.67% · Performance 19.29% · Measure score 4.62 · Achievement 4.61 · Improvement 4.62
Healthcare-associated infections
3.70
Baseline 6.65% · Performance 6.73% · Measure score 3.70 · Achievement 3.70 · Improvement 0
Total nurse turnover
3.18
Baseline 51.06% · Performance 50.68% · Measure score 3.18 · Achievement 3.18 · Improvement 0
Adjusted total nurse staffing
6.34
Baseline 4.08 hours · Performance 4.88 hours · Measure score 6.34 · Achievement 6.34 · Improvement 4.22
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.99% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 236 · Observed rate 7.63% · Lower 95% interval 7.07% |
| Discharge to community | 52.76% |
50.57%
2.2 pts better
|
No Different than the National Rate · Eligible stays 269 · Observed rate 51.3% · Lower 95% interval 48.63% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 161 · Denominator 161 |
| Falls with major injury | 0.62% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 161 |
| Discharge self-care score | 69.67% |
53.69%
16 pts better
|
Numerator 85 · Denominator 122 |
| Discharge mobility score | 77.87% |
50.94%
26.9 pts better
|
Numerator 95 · Denominator 122 |
| Pressure ulcers or injuries, new or worsened | 3.11% |
2.29%
0.8 pts worse
|
Numerator 5 · Denominator 161 · Adjusted rate 3.5% |
| Healthcare-associated infections requiring hospitalization | 6.73% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 151 · Observed rate 5.3% · Lower 95% interval 4.23% |
| Staff COVID-19 vaccination coverage | 7.49% |
8.2%
0.7 pts worse
|
Numerator 26 · Denominator 347 |
| Staff flu vaccination coverage | 37.5% |
42%
4.5 pts worse
|
Numerator 213 · Denominator 568 |
| Discharge function score | 72.13% |
56.45%
15.7 pts better
|
Numerator 88 · Denominator 122 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 36 · Denominator 36 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 98 · Denominator 98 |
| Resident COVID-19 vaccinations up to date | 30% |
25.2%
4.8 pts better
|
Numerator 27 · Denominator 90 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.7
1.2 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.6 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
95.3%
3.8 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
3.0%
3.4 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.1% · Q3 5.8% · Q4 9.3% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
18.5%
17.1 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.0% · Q3 2.0% · Q4 0.9% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 8.6% |
6.1%
2.5 pts worse
|
5.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 12.3% · Q3 10.2% · Q4 4.2% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.8% |
13.5%
0.3 pts worse
|
19.6%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 17.6% · Q3 15.0% · Q4 12.5% · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.5% |
14.8%
2.3 pts better
|
16.7%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 9.4% · Q3 13.1% · Q4 13.4% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.7% |
15.1%
8.6 pts worse
|
16.3%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 22.7% · Q3 17.0% · Q4 22.9% · 4Q avg 23.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.2% |
15.5%
8.7 pts worse
|
14.9%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 31.7% · Q3 16.7% · Q4 24.2% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.6%
0.3 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.9% · Q3 0.0% · Q4 0.6% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.4%
0.5 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 1.9% · Q4 2.5% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.1% |
20.8%
12.3 pts worse
|
19.8%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 37.8% · Q3 29.6% · Q4 32.5% · 4Q avg 33.1% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
6.9%
1.6 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.9% · Q3 9.2% · Q4 6.1% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
76.7%
22.9 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 99.2% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.0% |
9.7%
0.7 pts better
|
12.0%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.0% · Observed 8.3% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 1.6% · Q3 1.9% · Q4 0.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.6% |
78.8%
18.8 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.1% |
20.6%
1.5 pts worse
|
23.9%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 19.0% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-18 · Fire 2023-12-18
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-05-31 · Fire 2022-05-31
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-08-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-08-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-08-08
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-09-21
E · Potential for more than minimal harm
2023-12-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-18
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-08
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-08-08
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-08-08
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-10-06
B · Minimal harm
2025-08-08
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-10-27
D · Potential for more than minimal harm
2023-12-18
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-18
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-12
D · Potential for more than minimal harm
2023-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-18
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-02-01
D · Potential for more than minimal harm
2022-05-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-06-21
Penalties and ownership
What sits behind the stars
Ownership
Akkinepally, Sita
Operational/Managerial Control · Individual
Chizuk, Steven
Operational/Managerial Control · Individual
Chizuk, Steven
Corporate Officer · Individual
Ingwersen, Candyce
Corporate Director · Individual
Koenig, Christopher
Operational/Managerial Control · Individual
Koenig, Christopher
Corporate Director · Individual
Koenig, Christopher
Corporate Officer · Individual
Lankes, Carol
Corporate Director · Individual
Mertzlufft, Paul
Corporate Director · Individual
Setlock, Shane
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Elderwood At Lancaster
Lancaster, NY
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Harris Hill Nursing Facility, L L C
Williamsville, NY
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Brothers Of Mercy Nursing & Rehabilitation Center
Clarence, NY
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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