Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenfield Health & Rehab Center during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment, who had a history of combative behaviors during care, was allegedly choked, pushed, and called expletive names by a CNA. Another CNA intervened and removed the resident from the situation but did not report the suspected abuse to a supervisor until the following day, contrary to facility policy and regulatory requirements for immediate reporting of alleged abuse to facility leadership and the State agency.
A resident with dementia, anxiety, and major depression received an increased Xanax dose without documented clinical indication. The chart showed the dose changed from 0.25 mg to 0.5 mg every 8 hours, while the psychiatry PA and NP documented continuation of the lower dose and no need for an increase. BMARC notes also lacked support for the higher dose, and staff interviews confirmed the order was transcribed incorrectly and that the resident had no behaviors or increased anxiety documented.
A resident with a Foley catheter, UTI history, and intact cognition was not consistently provided a leg bag when out of bed, despite preferring one and using one at home. Observations showed gravity drainage tubing hanging from the bed and wheelchair with tubing touching the floor, including under the resident’s feet. Staff, including CNAs, LPNs, the DON, and the NP, stated the tubing should not touch the floor and that ambulatory residents with Foley catheters should have a leg bag; the record did not document a refusal of care.
A resident with endocarditis and a central venous catheter returned from the hospital needing daily IV ceftriaxone, but the admission process relied on a preliminary report and did not initially capture the final discharge summary orders. Staff did not enter orders for IV antibiotics or central line maintenance right away, and the resident reported missed flushes and delayed antibiotic administration. Interviews showed multiple nurses and leadership did not question the missing orders despite knowing the resident had a central line and needed ongoing IV therapy.
Arbitration Agreement Did Not Provide Required 30-Day Rescission Period: The facility used an arbitration form that allowed only a 7-day rescission period instead of the required 30 days for three residents reviewed. The residents were cognitively intact, and one resident’s POA signed the agreement. Interviews with admissions and leadership staff confirmed they used the 7-day language and were unaware of the 30-day requirement.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an alleged incident of staff-to-resident abuse was reported immediately to facility administration and to the State agency within required time frames. Facility policy dated January 2023 required all employees to report any act of resident abuse by a staff member or another resident immediately to their supervisor upon knowledge of the alleged abuse. Resident #1, who had dementia, severe cognitive impairment, and a history of verbal and physical behaviors including combativeness during care and hitting staff, was the subject of the allegation. The resident’s care plan directed staff to intervene to protect the resident and others, redirect negative behaviors, and remove the resident from situations as needed. On the evening of 02/18/2026 at approximately 9:30 PM, Certified Nurse Aide (CNA) #2 reported later that they witnessed CNA #1 choking Resident #1, calling the resident expletive names, and pushing the resident out of the room in an aggressive manner. CNA #2 removed the resident from the situation but did not report the allegation to a supervisor or charge nurse that night. Instead, CNA #2 reported the incident to Registered Nurse Resident Care Coordinator #1 the following morning at about 10:40 AM, stating they did not realize what they had seen until the next day. The Resident Care Coordinator then reported the allegation to the Administrator at approximately 10:45 AM. Interviews with supervisory staff and the Administrator confirmed that no abuse allegation was reported during the evening shift when the incident allegedly occurred, and that staff were expected to report suspected abuse immediately, which did not occur in this case.
Unnecessary Xanax Dose Increase Without Supporting Indication
Penalty
Summary
Unnecessary psychotropic medication use was identified for one resident who had diagnoses of dementia, anxiety, and major depression and whose MDS showed severe cognitive impairment, no delusions, no hallucinations, no rejection of care, no behaviors, and use of antianxiety medication. The resident’s care plan identified Xanax for anxiety disorder, with interventions to administer it as ordered and monitor for side effects and effectiveness every shift. Facility policies required medication regimen review and review of psychopharmacological agents to ensure appropriate indications, dose, frequency, and route. The resident’s medication record showed Xanax 0.25 mg every 8 hours through 01/30/2025, after which the active order became Xanax 0.5 mg every 8 hours. However, progress notes from the psychiatry PA and the NP repeatedly documented continuation of Xanax 0.25 mg every 8 hours and stated there was no need for an increase or additional psychotropic medications. The BMARC follow-up notes also documented Xanax use but did not include any documented indication for the dose increase. Review of the MAR showed the resident received the medication as ordered, but the record did not contain evidence supporting why the dose was increased. Survey interviews found no documented clinical indication for the higher dose. The psychiatry PA stated they did not recommend increasing Xanax and later said the documentation on the higher dose was a mistake and that they had assumed it was the previous dosage. The NP stated they did not give a verbal order to increase the dose and that the order had been transcribed inaccurately. The unit manager stated the order was entered incorrectly and should have remained Xanax 0.25 mg every 8 hours, and the DON stated there was no evidence supporting the increase and that the resident was taking the incorrect dosage. Observations during the survey showed the resident was pleasant, cooperative, self-propelling the unit, participating in activities, and displaying no behaviors.
Foley Catheter Tubing Left on Floor and Leg Bag Not Provided
Penalty
Summary
The facility did not ensure appropriate catheter care and infection control practices for a resident with an indwelling Foley catheter. The resident had diagnoses including urinary tract infection, benign prostatic hypertrophy, and neuromuscular dysfunction of the bladder. The resident’s MDS documented that they were cognitively intact and understood care, and the record did not show refusals of care. The care plan and Kardex addressed keeping the catheter bag and tubing below bladder level, but they did not address use of a leg bag when the resident was out of bed, even though the resident walked with assistance and used a hemi-walker. During observations, the resident was seen with a gravity drainage bag in a blue privacy bag hanging on the bedframe and later attached under a wheelchair, with catheter tubing touching the floor. One observation showed about four inches of tubing touching the floor beside the bed, and another showed about 16 inches of tubing under the wheelchair with the resident’s feet on the tubing. The resident stated they preferred a leg bag, used one at home, and wanted one during therapy because they were afraid the tubing could get caught while walking and rip the catheter out. The resident also stated they were not offered a leg bag in the morning and did not understand why they were not given one. Staff interviews confirmed that residents with Foley catheters who ambulated or attended therapy were expected to have a leg bag, and that drainage tubing should not touch the floor. Multiple CNAs and nurses stated that the tubing on the floor was an infection control issue and that staff were responsible for keeping the tubing in the privacy bag and off the floor. The DON/Infection Preventionist stated that if a resident refused a leg bag, it should have been documented in a nursing note, but the record reviewed did not contain documentation of a refusal. The resident had a recent urinary tract infection, and the NP stated the tubing should never be on the floor because of migrating bacteria increasing infection risk.
Missed IV Antibiotic and Central Line Maintenance Orders
Penalty
Summary
Safe, appropriate administration of IV fluids was not provided for a resident who had diagnoses including diabetes mellitus, endocarditis, and cellulitis and who returned from the hospital with a central venous catheter in the right upper chest. The resident’s comprehensive care plan identified IV medications related to endocarditis/bacteremia, and the hospital final discharge summary stated the resident was to receive ceftriaxone 2 grams IV daily through completion of the antibiotic course. However, the active physician orders initially contained no orders for central venous catheter maintenance and care, including normal saline flushes and dressing changes, and no physician orders for IV antibiotics were present when the resident was admitted. The facility’s records showed that orders for central line flushes and line measurement were not initiated until several days after admission, and the order for ceftriaxone IV and weekly dressing/tubing changes was not added until later. Review of the 24-hour report sheets for the first several days after admission showed no documented evidence that the resident had a central venous catheter, received maintenance flushes, or received IV antibiotic medication. During observation, the resident stated the central venous catheter had not been flushed for two days after arrival and that the IV antibiotic was not started until later, despite the resident providing discharge paperwork to staff on admission. Interviews with nursing staff and leadership showed that the preliminary hospital report was used for medication entry, but the final discharge summary was not reviewed at the time of admission. Staff stated they did not question the absence of orders for the central venous catheter or IV antibiotic therapy even though the resident had a central line and the discharge summary referenced ongoing IV ceftriaxone. The DON, unit manager, nursing supervisors, LPNs, and NP all acknowledged that the discrepancy should have been identified sooner, and the facility identified that the resident missed IV antibiotics and saline flushes during the early admission period.
Arbitration Agreement Did Not Provide Required 30-Day Rescission Period
Penalty
Summary
The facility did not ensure its Binding Arbitration Agreement explicitly granted residents and their representatives the right to rescind the agreement within 30 calendar days of signing it for three residents reviewed during the survey. The facility’s undated Arbitration Agreement stated that the resident or representative could cancel the agreement within seven calendar days of execution by written notice to the facility, and the agreement became part of the admission agreement upon execution. Resident #104 had diagnoses including fracture of the hip, hypertension, and depression, and was documented as cognitively intact on the MDS; the resident signed the Arbitration Agreement on 10/03/2024. Resident #118 had diagnoses including hypertension, atrial fibrillation, and depression, was also documented as cognitively intact, and signed the agreement on 06/26/2025. Resident #152 had diagnoses including heart failure, hypertension, and atrial fibrillation, was documented as cognitively intact, and the resident’s POA signed the agreement on 05/21/2025. Interviews with the Director of Admissions, the Administrator, and the President of Business Development confirmed the facility used the seven-day rescission language, and staff stated they were unaware that federal regulation required a 30-day rescission period for residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elderwood At Lancaster | 2.7 mi | ★★★★★ | 2 | 0 |
| Harris Hill Nursing Facility, L L C | 5.1 mi | ★★★★★ | 9 | 0 |
| Brothers Of Mercy Nursing & Rehabilitation Center | 5.2 mi | ★★★★★ | 24 | 0 |
| Elderwood At Cheektowaga | 5.8 mi | ★★★★★ | 4 | 0 |
| Garden Gate Health Care Facility | 6.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.