Inspection Reports for
Newfane Rehab & Health Care Center
2709 Transit Rd, Newfane, NY, 14108
Back to Facility ProfileCitations (last 3 years)
Citations (over 3 years)
14.3 citations/year
Citations are regulatory findings recorded during state inspections.
180% worse than New York average
New York average: 5.1 citations/yearCitations per year
24
18
12
6
0
Inspection Report
Routine
Citations: 9
Date: Jun 5, 2025
Visit Reason
The facility underwent a standard routine survey inspection to assess compliance with regulatory requirements related to resident care, safety, medication management, and facility environment.
Findings
The inspection identified multiple deficiencies including unsanitary conditions and maintenance issues in resident areas, failure to ensure gradual dose reductions for psychotropic medications, incomplete or missing physician order signatures, inadequate resident assessments, lack of proper notification for resident transfers, insufficient supervision for a wandering resident, improper use and maintenance of bed rails, and failure to provide medically-related social services for a resident wishing to return to the community.
Citations (9)
F 0584: The facility failed to maintain a safe, clean, and homelike environment with issues such as foul odors, soiled linens, missing or cracked tiles, and unlabeled personal items in shared bathrooms across multiple units.
F 0605: The facility did not ensure gradual dose reductions of psychotropic medications for two residents, lacking physician documentation of clinical contraindications.
F 0628: The facility failed to notify residents, representatives, or ombudsman in writing of transfers or discharges for two residents hospitalized during the survey period.
F 0636: The facility did not complete comprehensive Minimum Data Set assessments within required timeframes for two residents.
F 0689: The facility failed to identify and evaluate wandering and exit-seeking behaviors for one resident, resulting in inadequate supervision and an unwitnessed fall.
F 0700: The facility did not assess risks, obtain consent, educate residents, or maintain bed rails properly for four residents; bed rails were loose and posed safety hazards.
F 0711: The facility did not ensure physician or non-physician provider signed and dated resident orders at least every 60 days for 13 residents reviewed.
F 0745: The facility failed to provide medically-related social services to assist one resident who wished to return to the community; no referral was made to outside agencies.
F 0756: The facility's pharmacist did not report irregularities or recommend gradual dose reductions for psychotropic medications, and documentation of such reviews was lacking.
Report Facts
Cracked floor tiles: 27
Unlabeled wash basins: 4
Soiled washcloths: 3
Bed rails loose movement: 1
Bed rail gap: 2
Residents reviewed for medication: 5
Residents with unsigned orders: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager #2 | Licensed Practical Nurse Unit Manager | Stated cleaning responsibilities for brown and black debris in shower rooms |
| District Manager of Environmental Services | District Manager of Environmental Services | Described housekeeping and nursing cleaning responsibilities and odor sources |
| Director of Plant Operations | Director of Plant Operations | Discussed plans for remodeling and safety hazards of missing tiles |
| Administrator | Administrator | Discussed housekeeping contract changes and policy absence for medical order review |
| Pharmacy Consultant | Pharmacy Consultant | Discussed lack of gradual dose reduction recommendations and documentation |
| Director of Social Work | Director of Social Work | Responsible for section Q of Minimum Data Set and social service referrals |
| Director of Nursing | Director of Nursing | Discussed expectations for assessments, order signing, and medication monitoring |
| Medical Director | Medical Director | Discussed responsibility for medication monitoring and order signing |
| Director of Therapy Services | Director of Therapy Services | Assessed bed rail use and safety for residents |
| Maintenance Assistant #1 | Maintenance Assistant | Discussed bed rail maintenance and safety inspections |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 13
Date: Jun 5, 2025
Visit Reason
Complaint Survey with 9 Standard Health citations and 4 Life Safety Code citations, all corrected as of August 1, 2025.
Findings
Complaint Survey with 9 Standard Health citations and 4 Life Safety Code citations, all corrected as of August 1, 2025.
Citations (13)
Bedrails — quality of care
Comprehensive assessments & timing — quality of care
Discharge process — quality of care
Drug regimen review, report irregular, act on — quality of care
Free of accident hazards/supervision/devices — quality of care
Physician visits - review care/notes/order — quality of care
Provision of medically related social service — quality of care
Right to be free from chemical restraints — quality of care
Safe/clean/comfortable/homelike environment — quality of care
Electrical systems - essential electric syste — life safety code
Electrical systems - other — life safety code
Sprinkler system - maintenance and testing — life safety code
Subdivision of building spaces - smoke barrie — life safety code
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 17
Date: Aug 11, 2023
Visit Reason
Complaint Survey with 10 Standard Health citations and 7 Life Safety Code citations, all corrected as of October 2, 2023.
Findings
Complaint Survey with 10 Standard Health citations and 7 Life Safety Code citations, all corrected as of October 2, 2023.
Citations (17)
ADL care provided for dependent residents — quality of care
Department criminal history review — quality of care
Food procurement,store/prepare/serve-sanitary — quality of care
Free of accident hazards/supervision/devices — quality of care
Maintains effective pest control program — quality of care
Notice requirements before transfer/discharge — quality of care
Nutritive value/appear, palatable/prefer temp — quality of care
Posted nurse staffing information — quality of care
Resident rights/exercise of rights — quality of care
Safe/clean/comfortable/homelike environment — quality of care
Corridor - doors — life safety code
Electrical systems - essential electric syste — life safety code
Fire alarm system - installation — life safety code
Hazardous areas - enclosure — life safety code
Illumination of means of egress — life safety code
Means of egress - general — life safety code
Sprinkler system - maintenance and testing — life safety code
Inspection Report
Routine
Citations: 4
Date: Jun 29, 2021
Visit Reason
The inspection was a standard survey conducted to assess compliance with nursing home regulations including employee screening, abuse reporting, resident transfer notifications, and infection control practices.
Findings
The facility failed to implement proper screening policies for licensed employees through the Nurse Aide Registry, did not timely report alleged abuse incidents, failed to notify residents and representatives of hospital transfers, and did not ensure proper hand hygiene during wound care and medication administration.
Citations (4)
F 0607: The facility did not implement written policies and procedures to screen licensed employees through the New York State Nurse Aide Registry prior to employment, affecting 27 licensed staff.
F 0609: The facility failed to timely report alleged abuse and resident-to-resident altercation incidents to the New York State Department of Health within the required two-hour timeframe.
F 0623: The facility failed to provide timely written notification to residents, representatives, and the ombudsman of facility-initiated hospital transfers for two residents.
F 0880: The facility did not ensure proper hand hygiene during wound care and medication administration, risking cross contamination among residents.
Report Facts
Licensed employees without Nurse Aide Registry verification: 27
Residents reviewed for alleged abuse: 4
Residents affected by abuse reporting deficiency: 2
Residents affected by transfer notification deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed failing to perform proper hand hygiene during wound care and medication administration. |
| Human Resources Director | Interviewed regarding failure to screen licensed employees through Nurse Aide Registry. | |
| Administrator | Interviewed regarding abuse reporting and transfer notification policies. | |
| Director of Social Work | Interviewed regarding notification of transfers and abuse allegations. | |
| RN #5 | Unit Manager | Interviewed regarding abuse investigation and reporting responsibilities. |
| DON | Director of Nursing | Interviewed regarding abuse reporting, infection control, and hand hygiene expectations. |
| RN UM #3 | RN Unit Manager | Interviewed regarding hand hygiene standards and wound care procedures. |
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