Inspection Reports for
Salamanca Rehabilitation & Nursing Center
451 Broad Street, Salamanca, NY, 14779
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of abuse, neglect, and regulatory compliance issues at Salamanca Rehabilitation & Nursing Center.
Complaint Details
The complaint investigation (NY00370043-694884) focused on alleged sexual abuse involving two residents. The facility failed to report the alleged abuse within the required two-hour timeframe to the administrator and state survey agency. The investigation found no documented evidence of abuse but identified failures in timely reporting and follow-up.
Findings
The facility was found deficient in multiple areas including failure to implement timely employee screening policies, delayed reporting of alleged abuse, inadequate assistance with activities of daily living, unsafe storage of medications, and failure to maintain a safe environment regarding resident smoking policies.
Deficiencies (5)
F 0607: The facility did not implement written policies and procedures for screening employees to prevent abuse, neglect, and exploitation. Five of ten employees were not reviewed through the New York State Nurse Aide Registry prior to employment.
F 0609: The facility failed to timely report suspected abuse and did not report the results of the investigation to proper authorities within required time frames for two residents involved in an alleged sexual abuse incident.
F 0677: Resident #8, dependent on staff for all activities of daily living, was not provided timely incontinent care and infection control practices were not maintained during care.
F 0689: The facility did not ensure residents remained free of accident hazards; Resident #19 had an e-cigarette/vape device stored in their room without order, care plan, or assessment for safe storage.
F 0761: Medications for Resident #21 were left unattended and unsecured on an over the bed table without physician orders for self-administration or bedside storage.
Report Facts
Employees not screened prior to employment: 5
Days worked before registry verification: 35
Days worked before registry verification: 37
Days worked before registry verification: 4
Days worked before registry verification: 9
Days worked before registry verification: 70
Residents reviewed for ADL: 5
Residents observed for accidents: 5
Units reviewed for medication storage: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Reported allegation of sexual abuse during complaint investigation. | |
| Registered Nurse #3 | Reported sexual abuse incident to Director of Nursing and assessed residents. | |
| Licensed Practical Nurse #1 | Failed to report alleged abuse to supervisor immediately. | |
| Certified Nurse Aide #5 | Involved in incontinent care with infection control lapses for Resident #8. | |
| Certified Nurse Aide #6 | Observed infection control lapses during Resident #8 care. | |
| Licensed Practical Nurse #2 Supervisor | Supervisor | Unaware of Resident #19's e-cigarette until after observation; secured device. |
| Certified Nurse Aide #4 | Observed unsecured medications in Resident #21's room but did not report. | |
| Assistant Director of Nursing | Reviewed medication orders and confirmed deficiencies in medication storage. | |
| Nurse Practitioner #1 | Stated it was unexpected to find volume of over-the-counter medications at bedside. | |
| Registered Nurse #1 Resident Care Coordinator | Resident Care Coordinator | Stated expectation that medications found in resident rooms be reported. |
| Director of Nursing | Stated expectations for medication storage and reporting of unsecured medications. |
Inspection Report
Routine
Deficiencies: 5
Date: Sep 1, 2023
Visit Reason
The inspection was a standard routine survey conducted to assess compliance with regulatory requirements related to resident safety, care, staffing, food service, and facility operations.
Findings
The facility was found to have multiple deficiencies including unsafe hot water temperatures exceeding 120°F in resident areas, inadequate catheter care for a resident with a suprapubic catheter leading to risk of urinary tract infections, failure to post accurate nurse staffing hours, suboptimal food temperatures and poor food quality, and improper food service hygiene practices including malfunctioning dishwasher and inadequate glove use.
Deficiencies (5)
F 0689: The facility failed to ensure resident water temperatures were maintained within safe limits, with multiple resident rooms measuring water temperatures above 120°F, posing a risk of scalding.
F 0690: Resident #69 with a suprapubic catheter did not receive appropriate catheter care, including lack of documented irrigation and failure to notify the physician of low or no urinary output, increasing risk of urinary tract infection.
F 0732: The facility did not post daily nurse staffing information accurately, omitting actual hours worked for RNs, LPNs, and CNAs on the staffing form.
F 0804: Food and beverages were served at suboptimal temperatures and were not palatable, with hot foods served lukewarm or cold and cold foods served warm, affecting resident satisfaction and safety.
F 0812: The facility failed to maintain food service safety standards, including a malfunctioning dishwasher without proper sanitization and inadequate hand hygiene and glove use by food service staff, risking cross contamination.
Report Facts
Water temperature readings: 127
Urinary output shifts with no output: 6
Urinary output shifts with low output: 5
Day shift census: 105
Staff scheduled day shift: 14
Test tray food temperatures: 123.3
Test tray food temperatures: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in catheter care deficiency related to Resident #69 |
| RN #1 | Registered Nurse | Named in catheter care deficiency related to Resident #69 |
| NP | Nurse Practitioner | Named in catheter care deficiency related to Resident #69 |
| DON | Director of Nursing | Named in catheter care deficiency and staffing deficiency |
| FSD #1 | Food Service Director | Named in food service temperature and hygiene deficiencies |
| Diet Tech #1 | Dietary Technician | Named in food service temperature and hygiene deficiencies |
| HR | Human Resource Manager | Named in staffing posting deficiency |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Sep 1, 2023
Visit Reason
Complaint Survey with 5 health deficiencies and 4 life safety code deficiencies, all corrected by October 24, 2023.
Findings
Complaint Survey with 5 health deficiencies and 4 life safety code deficiencies, all corrected by October 24, 2023.
Deficiencies (9)
Bowel/bladder incontinence, catheter, uti
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Nutritive value/appear, palatable/prefer temp
Posted nurse staffing information
Elevators
Fire alarm system - installation
Gas equipment - cylinder and container storag
Sprinkler system - maintenance and testing
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jun 14, 2023
Visit Reason
Complaint Survey with 2 health deficiencies related to accident hazards and notification of changes, both corrected by July 27, 2023.
Findings
Complaint Survey with 2 health deficiencies related to accident hazards and notification of changes, both corrected by July 27, 2023.
Deficiencies (2)
Free of accident hazards/supervision/devices
Notify of changes (injury/decline/room, etc. )
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jun 14, 2023
Visit Reason
The survey was conducted as an abbreviated survey including complaint investigations related to notification of resident status changes and supervision to prevent resident elopement.
Complaint Details
The abbreviated survey included complaint investigations (Complaint #'s NY00297795 and NY00298518) related to failure to notify family of resident condition changes and inadequate supervision leading to resident elopements.
Findings
The facility failed to immediately notify a resident's representative of significant health status changes and failed to provide adequate supervision to prevent elopement for two residents. The facility's security and staffing practices contributed to these deficiencies.
Deficiencies (2)
F 0580: The facility did not immediately inform Resident #1's representative of significant changes in the resident's health status related to hyperglycemia and new insulin orders.
F 0689: The facility failed to provide adequate supervision to prevent elopement for Residents #11 and #12, who eloped from the facility due to insufficient monitoring and security controls.
Report Facts
Insulin injection units: 20
Insulin injection units: 30
Elopement incidents: 2
Reception desk coverage hours: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in failure to notify resident's responsible party of condition change |
| RN #2 | Nursing Supervisor | Interviewed regarding notification procedures for resident condition changes |
| Director of Nursing | Director of Nursing (DON) | Provided statements on notification expectations and elopement investigations |
| Administrator | Facility Administrator | Provided statements on notification and front desk coverage policies |
| CNA #3 | Certified Nurse Aide | Witnessed Resident #11 elopement and described front desk staffing |
| Dietary Employee #1 | Dietary Employee | Assisted in locating and returning Resident #11 after elopement |
| Environmental Services Director | Environmental Services Director | Described facility lockdown system and door keypad controls |
| Former Director of Nursing | Former Director of Nursing (DON) | Conducted elopement investigations and provided historical context |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 29, 2023
Visit Reason
Complaint Survey with 1 health deficiency related to respiratory/tracheostomy care, corrected by May 4, 2023.
Findings
Complaint Survey with 1 health deficiency related to respiratory/tracheostomy care, corrected by May 4, 2023.
Deficiencies (1)
Respiratory/tracheostomy care and suctioning
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 29, 2023
Visit Reason
The abbreviated survey was conducted based on a complaint (#NY00313271) to investigate the facility's provision of respiratory care for a resident requiring a non-invasive mechanical ventilator.
Complaint Details
The survey was complaint-driven (Complaint #NY00313271). The complaint was substantiated as the facility failed to provide appropriate respiratory care and removed the ventilator without proper orders or policy.
Findings
The facility failed to provide appropriate respiratory care by inaccurately documenting and removing a non-invasive mechanical ventilator for Resident #1, substituting it with a CPAP machine order. The ventilator removal caused anxiety for the resident and was contrary to professional standards and the resident's care needs.
Deficiencies (1)
F 0695: The facility did not ensure safe and appropriate respiratory care for Resident #1 by inaccurately documenting the use of a non-invasive mechanical ventilator as a CPAP machine and removing the ventilator on 3/22/23. The facility lacked a policy for the ventilator and failed to provide necessary respiratory support consistent with professional standards.
Report Facts
Residents Affected: 3
Oxygen flow rate: 3
Dates of vendor contact attempts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse and Resident Care Coordinator | Responsible for inaccurately documenting the CPAP order and maintaining the treatment record; acknowledged the error and the failure to clarify the machine type on admission. |
| Administrator | Instructed the vendor to remove the ventilator on 3/22/23 and stated the resident was admitted with a CPAP machine. | |
| Operations Manager/Respiratory Therapist | Provided information about the ventilator and vendor contact attempts; involved in removal of the ventilator. | |
| Corporate Supervising Administrator | Stated uncertainty about the machine type and responsibility for respiratory services; committed to resolving the issue. | |
| Medical Director | Explained the difference between ventilator and CPAP/BiPAP and stated the ventilator removal was inappropriate. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 5, 2021
Visit Reason
Covid-19 Survey with 1 health deficiency related to sufficient nursing staff, corrected by December 27, 2021.
Findings
Covid-19 Survey with 1 health deficiency related to sufficient nursing staff, corrected by December 27, 2021.
Deficiencies (1)
Sufficient nursing staff
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Jul 30, 2021
Visit Reason
The survey was conducted as an abbreviated survey triggered by a complaint (Complaint #NY00262897) and included a standard survey to assess compliance with regulatory requirements.
Complaint Details
The abbreviated survey was conducted in response to Complaint #NY00262897 regarding inadequate supervision leading to resident elopement.
Findings
The facility was found deficient in ensuring adequate supervision to prevent resident elopement, maintaining safe and appetizing food temperatures, proper food service sanitation and staff hygiene, and infection control practices during COVID-19 specimen collection.
Deficiencies (4)
F 0689: The facility failed to identify and reassess a resident with exit seeking behaviors, resulting in elopement of Resident #5. No care plan or interventions for wandering or elopement risk were developed.
F 0804: The facility did not provide food and drink at safe and appetizing temperatures; hot foods were served lukewarm or cold and cold foods were not kept below 40°F, affecting multiple residents.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including improper dishwasher temperatures, unsanitized food processor equipment, and staff not wearing beard guards.
F 0880: The facility failed to ensure proper infection control during COVID-19 specimen collection; RN #2 did not wear gloves, gown, or N95 mask and wore surgical mask below the nose while swabbing a visitor.
Report Facts
Dishwasher wash cycle temperature: 141
Dishwasher rinse cycle temperature: 153
Dishwasher wash cycle temperature: 140
Dishwasher rinse cycle temperature: 160
Dishwasher wash cycle temperature: 140
Dishwasher rinse cycle temperature: 175
Dishwasher wash cycle temperature: 140
Dishwasher rinse cycle temperature: 140
Dishwasher wash cycle temperature: 150
Dishwasher rinse cycle temperature: 140
Food temperature: 121
Food temperature: 51
Food temperature: 52.5
Food temperature: 142
Food temperature: 115
Food temperature: 138
Food temperature: 55
Food temperature: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in infection control deficiency for improper PPE use during COVID-19 specimen collection |
| LPN #3 | Licensed Practical Nurse | Mentioned in relation to elopement assessment responsibilities and resident wandering |
| RN #3 | Resident Care Coordinator | Mentioned in relation to elopement risk assessment and resident supervision |
| Director of Nursing | Director of Nursing | Interviewed regarding elopement supervision expectations and infection control policies |
| Administrator | Facility Administrator | Interviewed regarding elopement incident and infection control expectations |
| Dietary Aide #3 | Dietary Aide | Mentioned in relation to food temperature monitoring and beard guard noncompliance |
| Dietary Technician | Dietary Technician | Mentioned regarding food preparation sanitation and dish machine temperature monitoring |
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