Inspection Reports for
Newfane Rehab & Health Care Center
2709 Transit Rd, Newfane, NY, 14108
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Inspection Report — Jun 5, 2025
Routine CMS
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 — Jun 5, 2025
State
Date: Jun 5, 2025
Visit Reason
State-compiled facility profile showing 15 inspections from 2022 to 2026 with citation and complaint history including enforcement actions.
Complaint Details
The state logged 166 complaints about this facility; 22 led to on-site inspections. One citation resulted from those complaints.
Findings
Across 15 inspections, 13 had no citations while 2 inspections resulted in 30 citations total, including 19 standard health and 11 Life Safety Code citations. The facility had 166 complaints with 22 on-site inspections and one enforcement action with fines recorded.
Citations (30)
Standard Health Citation — quality of care: Bedrails issue noted.
Standard Health Citation — quality of care: Comprehensive Assessments and Timing deficiencies.
Standard Health Citation — quality of care: Discharge Process deficiencies.
Standard Health Citation — quality of care: Drug Regimen Review, Report Irregularities, and Failure to Act.
Standard Health Citation — quality of care: Failure to be Free Of Accident Hazards/supervision/devices.
Standard Health Citation — quality of care: Physician Visits - Review Care/notes/order deficiencies.
Standard Health Citation — quality of care: Provision Of Medically Related Social Service deficiencies.
Standard Health Citation — quality of care: Right To Be Free From Chemical Restraints issues.
Standard Health Citation — quality of care: Safe, clean, comfortable, homelike Environment issues.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System deficiencies.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Other deficiencies.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficiencies.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrier issues.
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents deficiencies.
Standard Health Citation — quality of care: Department Criminal History Review issues.
Standard Health Citation — quality of care: Food Procurement, storage, preparation, and sanitary service deficiencies.
Standard Health Citation — quality of care: Failure to be Free Of Accident Hazards/supervision/devices.
Standard Health Citation — quality of care: Maintains Effective Pest Control Program deficiencies.
Standard Health Citation — quality of care: Notice Requirements Before Transfer/discharge issues.
Standard Health Citation — quality of care: Nutritive Value, appearance, palatability, and preferred temperature issues.
Standard Health Citation — quality of care: Posted Nurse Staffing Information deficiencies.
Standard Health Citation — quality of care: Resident Rights and exercise Of Rights issues.
Standard Health Citation — quality of care: Safe, clean, comfortable, homelike Environment issues.
Life Safety Code Citation — NFPA requirements: Corridor Doors deficiencies.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System deficiencies.
Life Safety Code Citation — NFPA requirements: Fire Alarm System Installation issues.
Life Safety Code Citation — NFPA requirements: Hazardous Areas Enclosure deficiencies.
Life Safety Code Citation — NFPA requirements: Illumination Of Means Of Egress deficiencies.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General issues.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficiencies.
Report Facts
Inspections on page: 15
Total violations/deficiencies cited: 30
Inspections with violations: 2
Inspections without violations: 13
Total complaints: 166
On-site complaint inspections: 22
Citations issued from complaints: 1
Enforcement actions: 1
Total fines: 2000
Inspection Report — Aug 11, 2023
Complaint Investigation CMS
Date: Aug 11, 2023
Visit Reason
The inspection was conducted as a complaint investigation to address multiple concerns including resident dignity during dining, housekeeping and maintenance issues, discharge/transfer notice deficiencies, inadequate assistance with activities of daily living, inadequate supervision to prevent accidents, improper food service, staffing posting issues, food safety and pest control problems.
Complaint Details
The complaint investigation (#NY00307977) was initiated due to concerns about resident dignity, environmental conditions, discharge notices, ADL care, supervision, food quality and safety, staffing postings, and pest control. The investigation confirmed multiple deficiencies in these areas.
Findings
The facility was found deficient in multiple areas including failure to provide timely meal service respecting resident dignity, unsanitary and poorly maintained environment with strong urine odors and damaged walls, inadequate discharge/transfer notices missing required information, failure to provide proper nail care, inadequate supervision of residents with swallowing difficulties, failure to post nurse staffing information correctly, serving food at unsafe temperatures and poor palatability, improper food storage and hygiene practices in kitchens and nourishment rooms, and ineffective pest control resulting in fly infestations in multiple units.
Citations (9)
F 0550: Resident #15 was not provided breakfast in a timely manner consistent with their care plan, resulting in a dignity issue.
F 0584: Facility failed to maintain a safe, clean, and homelike environment with strong urine odors, crumbling drywall, stained ceilings, missing baseboards, peeling wallpaper, dusty vents, and torn mattresses in multiple resident units.
F 0623: Resident #417 did not receive a proper written notice of transfer/discharge containing required information including transfer location and appeal rights.
F 0677: Resident #144 did not receive adequate nail care; fingernails were jagged with dark debris despite care plans and orders.
F 0689: Resident #160 with dysphagia received food inconsistent with prescribed pureed diet and lacked adequate supervision and cueing during meals to prevent aspiration.
F 0732: Facility did not post daily nurse staffing information including total number of licensed and unlicensed staff per shift.
F 0804: Food served was at suboptimal temperatures, unappetizing in appearance and flavor, and inconsistent with menu descriptions across multiple units.
F 0812: Food storage and preparation areas had outdated and undated food items, staff with facial hair not wearing beard guards, personal belongings stored in nourishment rooms, and lack of freezer thermometers.
F 0925: Facility failed to maintain an effective pest control program; multiple units had fly infestations including resident rooms and common areas.
Report Facts
Temperature: 121.5
Temperature: 110.7
Temperature: 143.5
Temperature: 51.3
Temperature: 56.1
Temperature: 124.3
Temperature: 141.2
Temperature: 107
Temperature: 50.4
Temperature: 58.1
Temperature: 129
Temperature: 137.5
Temperature: 125.7
Temperature: 52.5
Temperature: 54.8
Temperature: 123
Temperature: 132.4
Temperature: 122.2
Temperature: 140
Temperature: 54.8
Temperature: 55.4
Temperature: 145.6
Temperature: 159
Temperature: 131.5
Temperature: 61
Pest count: 400
Pest count: 150
Pest count: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide #1 | Dietary Aide | Observed with facial hair not wearing beard guard during food preparation |
| Certified Nurse Aide #2 | CNA | Interviewed regarding dignity issue with Resident #15's breakfast tray |
| Licensed Practical Nurse #3 | LPN | Interviewed regarding Resident #15's breakfast tray delivery |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding Resident #15's care plan for meals in bed |
| Registered Dietitian | RD | Interviewed regarding meal tray timing and food temperatures |
| Director of Nursing | DON | Interviewed regarding dignity issue and food service concerns |
| Licensed Practical Nurse Unit Manager #6 | LPN UM | Interviewed regarding Resident #160 diet upgrade and meal supervision |
| Speech Language Pathologist | SLP | Interviewed regarding Resident #160 swallowing evaluation and diet recommendations |
| Food Service Director | FSD | Interviewed regarding food temperatures and kitchen observations |
| Director of Plant Operations | Director of Plant Operations | Interviewed regarding environmental maintenance and pest control |
| Administrator | Administrator | Interviewed regarding staffing postings, pest control, and discharge notices |
Inspection Report — Jun 29, 2021
Routine CMS
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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