Inspection Reports for
Buffalo Center for Rehabilitation and Nursing
1014 Delaware Ave, Buffalo, NY, 14209
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Inspection Report — Nov 12, 2025
Complaint Investigation State
Date: Nov 12, 2025
Visit Reason
State-compiled facility profile showing 15 inspections from 2022 to 2026 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 262 complaints about this facility; 39 led to on-site inspections. The facility received 137.3 complaints per 100 beds versus a statewide rate of 57.4. 19 citations resulted from those complaints.
Findings
Across 15 inspections, 7 resulted in citations totaling 73 deficiencies primarily related to standard health and Life Safety Code issues. The facility had multiple enforcement actions and a high volume of complaints with on-site inspections.
Citations (44)
Free From Abuse And Neglect: Multiple citations found across inspections indicating failure to ensure residents were free from abuse and neglect.
Free Of Accident Hazards/supervision/devices: Citations for failure to maintain a safe environment free of accident hazards.
Investigate/prevent/correct Alleged Violation: Citations for inadequate investigation and correction of alleged violations.
Reporting Of Alleged Violations: Failure to properly report alleged violations as required.
Right To Access/purchase Copies Of Records: Violations related to resident rights to access or purchase copies of records.
Administration: Deficiencies in administrative functions impacting quality of care.
ADL Care Provided For Dependent Residents: Inadequate assistance with activities of daily living for dependent residents.
Bowel/bladder Incontinence, Catheter, Uti: Deficiencies in managing incontinence and catheter-related infections.
Comprehensive Assessments & Timing: Failure to conduct timely and comprehensive resident assessments.
Department Criminal History Review: Issues with conducting required criminal history reviews.
Infection Prevention & Control: Deficiencies in infection prevention and control practices.
Maintains Effective Pest Control Program: Failure to maintain an effective pest control program.
Pharmacy Srvcs/procedures/pharmacist/records: Deficiencies in pharmacy services and recordkeeping.
Posted Nurse Staffing Information: Failure to post required nurse staffing information.
Qapi/qaa Improvement Activities: Deficiencies in quality assurance and performance improvement activities.
Quality Of Care: Multiple citations related to overall quality of care provided.
Resident Rights/exercise Of Rights: Violations of resident rights and their exercise.
Safe/clean/comfortable/homelike Environment: Failure to maintain a safe and comfortable environment.
Tube Feeding Mgmt/restore Eating Skills: Deficiencies in tube feeding management and restoring eating skills.
Antibiotic Stewardship Program: Deficiencies in antibiotic stewardship practices.
Covid-19 Testing-residents & Staff: Failures in COVID-19 testing protocols for residents and staff.
Drug Regimen Is Free From Unnecessary Drugs: Issues with ensuring drug regimens are free from unnecessary medications.
Drug Regimen Review, Report Irregular, Act On: Deficiencies in drug regimen review and reporting irregularities.
Food Procurement,store/prepare/serve-sanitary: Violations in sanitary food procurement and preparation.
Medicaid/medicare Coverage/liability Notice: Deficiencies in coverage and liability notices.
Cooking Facilities: Life Safety Code violations related to cooking facilities.
Corridor - Doors: Life Safety Code violations regarding corridor doors.
Discharge From Exits: Life Safety Code issues with discharge from exits.
Doors With Self-closing Devices: Life Safety Code violations for doors with self-closing devices.
Egress Doors: Life Safety Code violations related to egress doors.
Electrical Equipment - Power Cords And Extens: Life Safety Code violations concerning electrical equipment and power cords.
Electrical Systems - Essential Electric Syste: Life Safety Code violations in essential electrical systems.
Emergency Lighting: Life Safety Code violations regarding emergency lighting.
Evacuation And Relocation Plan: Life Safety Code deficiencies in evacuation and relocation plans.
Exit Signage: Life Safety Code violations related to exit signage.
Fire Drills: Life Safety Code violations concerning fire drills.
Hazardous Areas - Enclosure: Life Safety Code violations in enclosure of hazardous areas.
Hvac: Life Safety Code violations related to HVAC systems.
Illumination Of Means Of Egress: Life Safety Code violations regarding illumination of egress paths.
Smoke Detection: Life Safety Code violations related to smoke detection systems.
Soiled Linen And Trash Containers: Life Safety Code violations concerning soiled linen and trash containers.
Sprinkler System - Maintenance And Testing: Life Safety Code deficiencies in sprinkler system maintenance and testing.
Subdivision Of Building Spaces - Smoke Barrie: Life Safety Code violations in subdivision of building spaces and smoke barriers.
Vertical Openings - Enclosure: Life Safety Code violations related to enclosure of vertical openings.
Report Facts
Inspections on page: 15
Total violations/deficiencies cited: 73
Inspections with violations: 7
Inspections without violations: 8
Total complaints: 262
On-site complaint inspections: 39
Citations from complaints: 19
Enforcement actions: 9
Total fines: 68000
Inspection Report — Jul 1, 2025
Complaint Investigation CMS
Date: Jul 1, 2025
Visit Reason
The inspection was conducted as an abbreviated partial extended survey triggered by a complaint (#NY00383127) regarding allegations of resident abuse involving inappropriate photographs taken and posted on social media by a Certified Nurse Aide.
Complaint Details
Complaint #NY00383127 involved allegations that a Certified Nurse Aide took and posted on social media photographs of incontinent residents in various stages of undress without consent. The complaint was substantiated with findings of actual harm and failures in reporting and investigation.
Findings
The facility failed to protect residents from sexual and mental abuse by staff when a Certified Nurse Aide took unauthorized photographs of incontinent residents in various stages of undress and posted them on social media. The facility also failed to timely report the suspected abuse to the State Agency and law enforcement within the required 2-hour timeframe. The investigation was incomplete, lacking thorough staff and resident interviews, and the administration treated the incident as a dignity concern rather than abuse.
Citations (4)
F 600: The facility failed to protect residents from abuse when a Certified Nurse Aide took unauthorized photographs of incontinent residents in various stages of undress and posted them on social media, causing psychosocial harm.
F 609: The facility did not report allegations of resident abuse to the State Department of Health and law enforcement within 2 hours as required.
F 610: The facility failed to thoroughly investigate alleged abuse, lacking comprehensive staff and resident interviews and excluding one resident from the investigation.
F 835: The facility was not administered effectively to ensure implementation of abuse policies and recognition of abuse, treating the incident as a dignity concern rather than abuse.
Report Facts
Residents reviewed for abuse: 6
Residents affected: 4
Social media post shares: 825
Staff reporting social media post: 8
Certified Nurse Aide witness statements: 5
Certified Nurse Aides on 5/25/25 7AM-3PM shift: 7
Certified Nurse Aides on 6/9/25 3PM-11PM shift: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Took unauthorized photographs of residents and posted them on social media; last day worked 06/01/2025. | |
| Administrator | Received reports of social media post, initiated investigation, but did not initially recognize abuse or report within required timeframe. | |
| Director of Nursing | Responsible for investigation; treated incident as dignity concern rather than abuse; received counseling for incomplete investigations. | |
| Director of Clinical Operations | Stated expectation for thorough investigation and timely reporting of suspected abuse. | |
| Social Worker #1 | Conducted dignity rounds; stated pictures were humiliating and degrading; did not interview families about social media post. | |
| Licensed Practical Nurse #1 | Stated social media pictures were a HIPAA violation, dignity issue, and could be considered mental and sexual abuse. | |
| Licensed Practical Nurse #2 | Stated pictures were never to be taken or posted; considered nudity and abuse. |
Inspection Report — Jun 17, 2025
Complaint Investigation CMS
Date: Jun 17, 2025
Visit Reason
Complaint investigations and recertification survey to assess compliance with regulatory requirements including resident care, infection control, medication management, and environmental conditions.
Complaint Details
Complaint investigations revealed multiple deficiencies including dignity violations due to flies, unsanitary conditions, medication errors, infection control breaches, and failure to provide ordered treatments and assessments.
Findings
The facility was found deficient in multiple areas including dignity and respect for residents due to fly infestations, unsafe and unsanitary environment conditions, failure to complete timely comprehensive resident assessments, inadequate personal care and grooming, failure to provide treatment and care according to orders, improper catheter care, failure to provide enteral feeding as ordered, inaccurate nurse staffing postings, pharmaceutical service deficiencies, inadequate infection prevention and control practices, and ineffective pest control program.
Citations (12)
F 0550: The facility failed to ensure residents were treated with dignity and respect, as flies were observed crawling on residents and their bed linens causing discomfort and undignified conditions.
F 0584: The facility did not provide a safe, clean, comfortable, and homelike environment; dirty shower chairs, uncovered soiled linen barrels, offensive odors, and unlabeled personal hygiene products were observed.
F 0636: The facility failed to complete comprehensive resident assessments within required time frames for 16 residents, delaying care planning and regulatory compliance.
F 0677: Residents who were unable to perform activities of daily living did not consistently receive necessary grooming and hygiene care; Resident #14 was observed with long dirty fingernails and unkempt facial hair despite care plans.
F 0684: The facility failed to provide treatment and care according to orders for residents; weights were not obtained as ordered for Residents #111 and #173, and surgical staples were not removed as ordered for Resident #47.
F 0690: The facility did not provide appropriate catheter care; urinary catheter bags were not emptied timely, tubing and bags were on the floor, and urine output was not monitored for Residents #47 and #382. Resident #47 lacked a catheter order initially.
F 0693: Resident #381 did not receive enteral feeding as ordered; feeding pump malfunction was not properly managed, resulting in missed nutrition and weight loss risk.
F 0732: The facility did not post accurate nurse staffing information daily; posted sheets were not updated each shift and did not reflect actual census or staff hours worked.
F 0755: Pharmaceutical services were deficient; Resident #380 missed antibiotic doses due to unavailable medication and lack of provider notification, and Resident #391 experienced delays in medication orders and administration upon admission.
F 0867: The facility failed to provide education and competency training to licensed nurses on enteral feeding pump use and documentation as required by their plan of correction.
F 0880: Infection prevention and control program deficiencies included failure to maintain enhanced barrier precautions; staff did not wear gowns when required for residents with feeding tubes, urinary catheters, PICC lines, and pressure ulcers. Enhanced Barrier Precaution signage was missing for Resident #165.
F 0925: The facility did not maintain an effective pest control program; multiple resident units had fly infestations, inadequate pest control measures, and lack of documentation of pest sightings.
Report Facts
Missed antibiotic doses: 6
Weight loss percentage: 16.7
Weight loss percentage: 2.74
Fly count: 50
Fly count: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #6 | Named in medication administration and missed antibiotic doses for Resident #380. | |
| Registered Nurse Supervisor #1 | Named in admission medication order entry issues for Resident #391. | |
| Licensed Practical Nurse #10 | Named in catheter care and monitoring deficiencies for Resident #47. | |
| Certified Nurse Aide #10 | Named in improper catheter bag emptying and infection control breaches for Resident #382. | |
| Licensed Practical Nurse Unit Manager #1 | Named in infection control and catheter care interviews. | |
| Director of Nursing | Named in multiple interviews regarding expectations for care, infection control, and medication management. | |
| Maintenance Director | Named in pest control and fly infestation management. | |
| Licensed Practical Nurse #3 | Named in enteral feeding administration and infection control interviews. | |
| Licensed Practical Nurse #7 | Named in enteral feeding pump malfunction and medication administration interviews. | |
| Registered Dietitian #1 | Named in weight monitoring and nutritional care interviews. | |
| Medical Director/Medical Doctor #1 | Named in interviews regarding medication and infection control expectations. |
Inspection Report — Apr 11, 2025
Complaint Investigation CMS
Date: Apr 11, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of staff altercation in front of residents and failure to thoroughly investigate an injury of unknown origin.
Complaint Details
Complaint #NY00364627 involved a staff altercation recorded and posted on social media violating resident privacy. Complaint #NY00375418 involved failure to investigate an injury of unknown origin for Resident #4. Both complaints were substantiated with findings of minimal harm.
Findings
The facility failed to ensure residents were treated with dignity and respect when staff engaged in a physical altercation in front of residents, which was recorded and posted on social media violating resident privacy. Additionally, the facility did not thoroughly investigate an injury of unknown origin sustained by a resident, resulting in inadequate abuse investigation procedures.
Citations (2)
F 0550: The facility did not ensure residents were treated with respect and dignity when staff fought in front of residents and the incident was recorded and posted on social media, violating resident privacy rights.
F 0610: The facility failed to thoroughly investigate an injury of unknown origin for a resident, despite policies requiring investigation of such injuries to ensure resident safety.
Report Facts
Residents affected: 3
Residents affected: 1
Dates of incidents: Dec 10, 2024
Dates of incidents: Mar 12, 2025
Dates of incidents: Mar 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Involved in physical altercation with Certified Nurse Aide #1. | |
| Certified Nurse Aide #1 | Involved in physical altercation with Licensed Practical Nurse #1. | |
| Licensed Practical Nurse #2 | Witnessed altercation and called 911. | |
| Licensed Practical Nurse Unit Manager #3 | Interviewed Resident #1 about altercation. | |
| Registered Nurse #1 | Provided information about altercation and privacy violation. | |
| Certified Nurse Aide #2 | Recorded altercation on cell phone and denied recording fight in interview. | |
| Certified Nurse Aide #3 | Described chaotic scene during altercation. | |
| Director of Nursing | Director of Nursing | Stated staff acted inappropriately during altercation and privacy violation. |
| Administrator | Administrator | Commented on impact of altercation and social media post on residents. |
| Licensed Practical Nurse Unit Manager #7 | Documented bruising on Resident #4 and involved in investigation. | |
| Licensed Practical Nurse Supervisor #6 | Documented decreased mobility of Resident #4 and interviewed about investigation. | |
| Licensed Practical Nurse Supervisor #4 | Assessed Resident #4's bruised area and interviewed about investigation. | |
| Licensed Practical Nurse Supervisor #5 | Documented hospital admission of Resident #4 and interviewed about investigation. | |
| Occupational Therapist | Performed range of motion exercises on Resident #4 and interviewed about pain signs. | |
| Medical Director | Medical Director | Provided orders and commented on investigation expectations. |
Inspection Report — May 7, 2024
Routine CMS
Date: May 7, 2024
Visit Reason
The inspection was a standard routine survey conducted to assess compliance with regulatory requirements related to resident care, safety, and pharmaceutical services at the Buffalo Center for Rehabilitation and Nursing.
Findings
The facility failed to ensure appropriate treatment and care for a resident requiring weekly blood tests and an intravenous catheter care plan. Additionally, the facility had unsafe hot water temperatures exceeding 120 degrees Fahrenheit on all resident floors. The facility also lacked proper pharmaceutical controls, including inadequate narcotic storage accountability and incomplete narcotic reconciliation records.
Citations (3)
F 0684: Resident #63 did not receive weekly c-reactive protein and erythrocyte sedimentation rate blood tests as ordered, and no care plan was developed for the use of an intravenous midline catheter.
F 0689: Hot water temperatures on four resident floors exceeded 120 degrees Fahrenheit, posing a risk of scalding; facility lacked proper monitoring and control of water temperatures.
F 0755: Facility did not maintain proper pharmaceutical services; narcotic storage lacked accountability logs, narcotic reconciliation shift counts were inconsistently signed, and the pharmacist consultant was not involved in narcotic processes.
Report Facts
Hot water temperature: 135.7
Duration of antibiotic order: 56
Narcotic reconciliation shifts missing signatures: 128
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Named in relation to omission of weekly blood work orders and care plan updates for Resident #63 |
| Medical Director | Medical Director | Documented orders and expectations for weekly blood tests for Resident #63 |
| Assistant Director of Nursing | Assistant Director of Nursing | Responsible for narcotic storage and accountability; noted lack of proper logs |
| Director of Nursing | Director of Nursing | Oversight of narcotic accountability and care plan expectations |
| Pharmacist Consultant | Pharmacist Consultant | Stated lack of involvement in narcotic processes and oversight |
Inspection Report — May 16, 2023
Abbreviated Survey CMS
Date: May 16, 2023
Visit Reason
The abbreviated survey was conducted as a complaint investigation related to alleged physical and verbal abuse of a resident by a Certified Nurse Aide (CNA).
Complaint Details
Complaint #NY00316275 was substantiated. The investigation confirmed physical and verbal abuse by CNA #1 against Resident #1.
Findings
The facility did not ensure Resident #1's right to be free from physical abuse. A CNA was witnessed hitting the resident with a pillow and using profanity. The facility conducted an investigation, suspended and terminated the CNA, and re-educated staff on abuse and neglect.
Citations (1)
F 0600: The facility failed to protect Resident #1 from physical and verbal abuse by a CNA who hit the resident with a pillow and used profanity. The facility identified the abuse and took corrective actions including staff suspension and re-education.
Report Facts
Residents Affected: 1
Dates of staff re-education: Staff were re-educated on 5/9/23, 5/10/23, and 5/12/23 post incident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PT #1 | Physical Therapist | Witnessed the abuse incident and reported it. |
| RN UM #1 | Registered Nurse Unit Manager | Responded to the abuse allegation and managed CNA suspension. |
| DON | Director of Nursing | Concluded abuse occurred and confirmed staff education on abuse. |
| Administrator | Facility Administrator | Reported the incident to the Department of Health and oversaw corrective actions. |
Inspection Report — Oct 18, 2022
Routine CMS
Date: Oct 18, 2022
Visit Reason
The inspection was a standard survey conducted to assess compliance with Medicare and Medicaid regulations, including review of resident care, medication management, infection control, and facility operations.
Complaint Details
Complaint investigation (Complaint #NY00296367) found failure to timely report resident-to-resident abuse involving two residents.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare notices to residents, untimely reporting of abuse, inadequate catheter care, medication errors including wrong enteral feeding formula, incomplete controlled substance reconciliation, failure to act on pharmacist recommendations, unnecessary long-term antibiotic use without proper monitoring, improper food storage and labeling, lack of an effective antibiotic stewardship program, and inadequate COVID-19 PPE use during specimen collection.
Citations (10)
F 0582: The facility failed to provide Skilled Nursing Facility Advance Beneficiary Notice and Notice of Medicare Non-Coverage to residents or responsible parties at Medicare coverage termination.
F 0609: The facility did not timely report a resident-to-resident altercation involving abuse to the Administrator and State Survey Agency within 2 hours as required.
F 0690: The facility failed to assess for removal and follow up with Urology for a resident with an indwelling catheter as ordered by the physician.
F 0693: The facility administered the wrong enteral feeding formula to a resident and documented it as correct, causing a medication error.
F 0755: The facility did not maintain accurate controlled substance records or reconcile injectable Lorazepam vials for a resident since April 2022.
F 0756: The facility failed to ensure pharmacist recommendations for medication regimen reviews were addressed and followed up for two residents.
F 0757: The facility did not ensure a resident's drug regimen was free from unnecessary drugs by continuing long-term antibiotic prophylaxis without indication or monitoring.
F 0812: The facility did not store and label resident food properly in nourishment room refrigerators, with multiple unlabeled, undated, and outdated food items found.
F 0881: The facility failed to implement an antibiotic stewardship program that monitors antibiotic use including prophylaxis, lacking protocols and tracking systems.
F 0886: The facility COVID-19 swabber did not wear required N95 mask and eye protection while collecting specimens, risking transmission.
Report Facts
Residents reviewed for abuse: 5
Residents affected by abuse reporting deficiency: 2
Duration of antibiotic prophylaxis: 14
Duration of antibiotic prophylaxis: Resident #10 received Macrobid daily for UTI prophylaxis with no stop date.
Date of survey completion: Oct 18, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in enteral feeding medication error finding. |
| LPN #8 | Licensed Practical Nurse | Named in resident-to-resident altercation reporting finding. |
| RN #3 | Registered Nurse | Named in resident-to-resident altercation reporting finding. |
| LPN #1 | Licensed Practical Nurse | Named in controlled substance reconciliation finding. |
| LPN #9 | Unit Manager | Named in pharmacist recommendation follow-up finding. |
| Pharmacy Consultant | Named in medication regimen review and antibiotic stewardship findings. | |
| Nurse Educator/Infection Preventionist | Named in COVID-19 PPE and antibiotic stewardship findings. | |
| Director of Nursing | Named in multiple findings including medication and infection control. | |
| Administrator | Named in abuse reporting and medication findings. | |
| Medical Director | Named in medication and antibiotic stewardship findings. |
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