Inspection Reports for
Gowanda Rehabilitation & Nursing Center
100 Miller Street, Gowanda, NY, 14070
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 3
Date: May 16, 2025
Visit Reason
The inspection was conducted as a standard survey to assess compliance with regulatory requirements related to resident care, safety, and facility practices.
Findings
The facility was found deficient in providing necessary grooming services to a resident, maintaining proper Foley catheter care to prevent urinary tract infections, and ensuring the correct installation and maintenance of bed rails. These deficiencies posed minimal harm or potential for actual harm to a few residents.
Deficiencies (3)
F 0677: The facility did not ensure Resident #30 received necessary grooming services, specifically removal of unwanted facial hair, despite care plans and policies requiring shaving as needed.
F 0690: The facility failed to maintain Foley catheter care for Resident #48, with catheter tubing lying on the floor, increasing risk of urinary tract infections despite documented care procedures.
F 0700: The facility did not ensure correct installation, use, and maintenance of bed rails for Resident #3; side rails were loose, not secure per manufacturer recommendations, and inspection documentation was inconsistent.
Report Facts
Residents reviewed for grooming: 4
Residents reviewed for Foley catheter care: 2
Residents reviewed for bed rail safety: 1
Length of facial hair: 0.25
Tubing length on floor: 18
Resident #3 weight: 267
Resident #3 height: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Named in failure to offer facial hair removal to Resident #30 during care. |
| Licensed Practical Nurse #1 | Unit Manager | Commented on expectations for shaving Resident #30 and staff responsibilities. |
| Assistant Director of Nursing/Educator | Stated expectations for staff to address facial hair removal for dignity reasons. | |
| Director of Nursing #1 | Director of Nursing | Stated expectations for shaving services and staff responsibilities for Resident #30. |
| Certified Nurse Aide #4 | Certified Nurse Aide | Observed Foley catheter tubing on floor and commented on infection risk for Resident #48. |
| Certified Nurse Aide #5 | Certified Nurse Aide | Noticed catheter tubing on floor and placed it in privacy bag for Resident #48. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Stated responsibility for proper catheter tubing placement. |
| Licensed Practical Nurse #4 | Unit Manager | Discussed staff responsibility for Foley catheter care and infection prevention. |
| Medical Director #1 | Medical Director | Expected staff to keep Foley catheter tubing off floor to prevent infections. |
| Medical Doctor #2 | Medical Doctor | Signed wound evaluation and management summary for Resident #48. |
| Certified Nurse Aide #2 | Certified Nurse Aide | Observed loose bed rails and assisted Resident #3 during care. |
| Certified Nurse Aide #3 | Certified Nurse Aide | Observed loose bed rails and assisted Resident #3 during care. |
| Occupational Therapist #1 | Occupational Therapist | Evaluated and commented on Resident #3's bed rails and recommended bed change. |
| Maintenance Assistant | Responsible for monthly inspection of bed rails and acknowledged missed documentation. | |
| Director of Therapy | Last checked Resident #3's bed rails and noted some movement but no concern. | |
| Licensed Practical Nurse #2 | Unit Manager | Commented on long-term use and instability of Resident #3's half side rails. |
| Maintenance Director | Stated Bari bed had loose side rails that were not secure. | |
| Administrator | Stated staff should have reported loose rails and rails should have been changed sooner. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: May 16, 2025
Visit Reason
Inspection identified multiple quality of care and life safety code deficiencies, all corrected as of July 10, 2025.
Findings
Inspection identified multiple quality of care and life safety code deficiencies, all corrected as of July 10, 2025.
Deficiencies (9)
ADL care provided for dependent residents
Bedrails
Bowel/bladder incontinence, catheter, uti
Electrical equipment - power cords and extens
Fire alarm system - testing and maintenance
Fire drills
Hazardous areas - enclosure
Portable space heaters
Subdivision of building spaces - smoke barrie
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Jul 25, 2023
Visit Reason
Complaint investigation and extended survey to assess compliance with regulations related to resident care, abuse reporting, supervision, staffing, infection control, and other regulatory requirements.
Complaint Details
The complaint investigation (#NY00311987) focused on issues including failure to notify physicians of significant changes, failure to report abuse and injuries timely, inadequate investigations, insufficient supervision leading to falls and wandering, inadequate nursing staffing, improper catheter care, and failure to provide ordered psychiatric evaluations.
Findings
The facility was found deficient in multiple areas including failure to immediately notify physicians of significant resident changes, failure to timely report and investigate allegations of abuse and injuries of unknown origin, inadequate care for residents dependent on staff for hygiene, inadequate supervision leading to resident falls and wandering, improper catheter care, lack of special training for PICC line removal, insufficient nursing staff to meet resident needs, failure to provide ordered telepsychiatric evaluations, and failure to implement an antibiotic stewardship program.
Deficiencies (9)
F 0580: The facility failed to immediately notify the physician of a resident's fractured elbow, delaying notification for several days.
F 0609: The facility failed to timely report suspected abuse and injuries of unknown origin to the state agency for four residents and did not conduct thorough investigations.
F 0677: The facility failed to provide adequate morning care including oral hygiene and perineal care for residents dependent on staff.
F 0689: The facility failed to provide adequate supervision to prevent accidents and wandering for a resident with severe cognitive impairment and history of falls, resulting in immediate jeopardy that was removed during the survey.
F 0690: The facility failed to provide appropriate catheter care and proper infection control when emptying urinary drainage bags for two residents with indwelling catheters.
F 0694: The facility allowed a Registered Nurse without documented special training or certification to remove a PICC line without a physician order and without proper infection control precautions.
F 0725: The facility did not maintain sufficient nursing staff to meet resident needs, frequently falling below minimum CNA staffing levels, impacting resident care and supervision.
F 0742: The facility failed to provide necessary behavioral health care and services, including failure to complete a telepsychiatric consult as ordered for a resident with explosive behaviors.
F 0881: The facility failed to implement an antibiotic stewardship program with appropriate monitoring and tracking of antibiotic use for a resident receiving prophylactic antibiotics.
Report Facts
Deficiencies cited: 9
Residents affected: 4
Falls: 8
Staffing shortfall: 3
Staffing shortfall: 1
Staffing shortfall: 3
Staffing shortfall: 2
Staffing shortfall: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Removed PICC line without documented special training or physician order. |
| LPN #2 | Licensed Practical Nurse / Unit Manager | Discussed helmet use and supervision for Resident #43 and catheter care expectations. |
| CNA #7 | Certified Nursing Aide | Observed providing bowel care without changing gloves or washing hands and improper catheter bag emptying. |
| DON | Director of Nursing | Discussed expectations for notification, catheter care, staffing, and antibiotic stewardship. |
| MD | Medical Director | Discussed expectations for PICC line removal, telepsychiatric consults, and antibiotic stewardship. |
| LPN #1 | Licensed Practical Nurse | Discussed supervision challenges and helmet use for Resident #43. |
| Pharmacy Consultant | Pharmacy Consultant | Discussed antibiotic stewardship and monitoring. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 25, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of failure to notify physicians of significant resident changes, failure to timely report suspected abuse or injuries, and inadequate investigations of alleged abuse or neglect.
Complaint Details
The complaint investigation (#NY00311987 & #NY00310989) found failures in physician notification, timely reporting to the state agency, and thorough investigations of abuse allegations involving multiple residents.
Findings
The facility failed to immediately notify the physician of a resident's fractured elbow, did not timely report suspected abuse or injuries to the state agency for four residents, and did not conduct thorough investigations including staff interviews for alleged abuse or neglect incidents.
Deficiencies (3)
F 0580: The facility did not ensure immediate physician notification for Resident #4's fractured elbow after x-ray results were available.
F 0609: The facility failed to timely report suspected abuse, neglect, or injuries of unknown origin to the New York State Department of Health for Residents #4, #17, #76, and #234.
F 0610: The facility did not conduct thorough investigations of alleged abuse or neglect, lacking complete staff interviews and documentation for Residents #4, #17, #76, and #234.
Report Facts
Date of survey completion: Jul 25, 2023
Bruise measurements: 7.4
Bruise measurements: 6
Skin tear size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Stated physician should be notified immediately of fractures |
| LPN #8 | Nurse Supervisor | Reported taking picture of x-ray and sending to on-call provider |
| PA | Physician Assistant | Did not recall notification about Resident #4's x-ray |
| RN #1 | Unit Manager | Did not receive information about Resident #4's x-ray |
| LPN #9 | Licensed Practical Nurse | Did not recall reporting Resident #4's x-ray results |
| RN #2 | Unit Manager | Stated physician should be notified immediately about x-ray results |
| DON | Director of Nursing | Stated physician or on-call provider should be notified immediately for fractures and injuries |
| Administrator | Expected immediate notification of physician and timely reporting of injuries | |
| LPN #1 | Licensed Practical Nurse | Noted purple bruise on Resident #4 and did not report it |
| LPN #2 | Unit Manager | Stated fresh bruises should be reported immediately and investigations initiated |
| LPN Supervisor #3 | Licensed Practical Nurse Supervisor | Stated fresh bruises from unknown origin require immediate reporting and investigation |
| LPN #16 | Licensed Practical Nurse | Notified nursing supervisor and initiated collecting statements for bruising investigation |
| LPN #3 | Licensed Practical Nurse | Recalled Resident #234 found in courtyard unsupervised |
| NP | Nurse Practitioner | Reviewed x-ray and commented on bruising and investigations |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 24, 2023
Visit Reason
The abbreviated survey was conducted based on Complaint #NY00304366 to investigate the facility's compliance with timely notification of laboratory test results to the ordering practitioner.
Complaint Details
Complaint #NY00304366 triggered the abbreviated survey. The complaint was substantiated as the facility delayed notifying the medical provider of a positive urine culture result, causing delayed treatment.
Findings
The facility failed to promptly notify the medical provider of a positive urine culture and sensitivity lab result for one resident, resulting in a delay in treatment. The delay was due to lack of assigned staff to monitor lab results during off shifts and weekends.
Deficiencies (1)
F 0773: The facility did not promptly notify the ordering practitioner of laboratory results that fell outside clinical reference ranges for one resident. Specifically, a positive urine culture and sensitivity result received on 10/21/22 was not communicated to the provider until 10/24/22, causing delayed treatment.
Report Facts
Dates of urine culture collection: Urine cultures collected on 10/17/22, 10/20/22, and 10/31/22 for Resident #1
Date positive urine culture reported: Positive urine culture reported on 10/21/22
Date medical provider notified: Medical provider reviewed lab on 10/24/22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Provided interview details about lab result notification process and delay | |
| Physician Assistant (PA) | Reviewed lab results on 10/24/22 and commented on delay in notification | |
| Director of Nursing (DON) | Provided interview details about staff responsibilities for lab result monitoring and notification |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 24, 2023
Visit Reason
Inspection identified a quality of care deficiency related to lab services physician order and notification of results, corrected as of May 26, 2023.
Findings
Inspection identified a quality of care deficiency related to lab services physician order and notification of results, corrected as of May 26, 2023.
Deficiencies (1)
Lab srvcs physician order/notify of results
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 17, 2021
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #NY00255554) regarding the facility's failure to provide an environment free from accident hazards and adequate supervision to prevent accidents, specifically related to a positioning bar equipment failure that caused a resident fall with injury.
Complaint Details
Complaint #NY00255554 was substantiated. The investigation found the facility did not maintain positioning bars properly, leading to equipment failure and resident injury.
Findings
The facility failed to ensure scheduled routine maintenance of positioning bars, resulting in a broken positioning bar that caused Resident #73 to fall and sustain multiple lacerations and abrasions. Interviews and document reviews revealed lack of routine maintenance, inadequate inspections, and communication failures regarding the positioning bars' safety.
Deficiencies (1)
F 0689: The facility did not provide an environment free from accident hazards and failed to ensure scheduled routine maintenance of positioning bars, resulting in a broken bar that caused Resident #73 to fall and sustain injuries including lacerations and abrasions.
Report Facts
Laceration size: 4
Laceration size: 0.5
Abrasion size: 6
Abrasion size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Documented hearing yelling and finding Resident #73 after fall |
| Director of Maintenance | Director of Maintenance | Observed broken positioning bar and described maintenance and inspection practices |
| Assistant Director of Nursing | Assistant Director of Nursing | Documented resident injuries after fall |
| Director of Rehab Services | Director of Rehab Services | Described Occupational Therapists' quarterly assessments of positioning bars |
| Certified Nurse Aide #1 | Certified Nurse Aide | Reported knowledge of maintenance reporting system and positioning bar issues |
| Director of Nurses | Director of Nurses | Interviewed about expectations for maintenance and inspections of positioning bars |
| Administrator | Administrator | Interviewed about expectations for scheduled inspections of positioning bars |
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