Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Absolut Center For Nursing And Rehabilitation At G during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, seizures, and documented wandering and exit-seeking behaviors, care planned with a wander monitoring device and identified as an elopement risk, was able to exit through a delayed egress front door without staff knowledge. Earlier that shift, the resident had been anxious, wandering, repeatedly calling for help, and had been assisted to bed by a CNA, while an LPN supervisor last saw the resident and assumed they had been put to bed. The resident pushed on the delayed egress door and left the building; video showed a CNA responding to the door alarm, looking into the entryway, silencing and resetting the alarm without opening the exterior doors or checking outside, and without notifying a supervisor. Facility policies on elopement and alarm response required staff to respond to alarms, prevent resident elopement, and follow an organized plan to locate missing residents, but the alarm was not escalated, and the resident was later found off premises by community responders.
The facility failed to maintain proper infection control practices, as staff did not adhere to enhanced barrier precautions for residents with indwelling medical devices or active infections. A resident with a PICC and scabies was not provided appropriate care, and two residents with foley catheters lacked necessary precautions. Additionally, the facility's infection preventionist did not adequately track a scabies outbreak, leading to incomplete contact tracing and management.
A resident with severe cognitive impairment and combative behavior was found with a bruise below the right eye. The facility failed to conduct a thorough investigation as required by policy, lacking staff interviews from previous shifts. The DON and Administrator attributed the injury to the resident's self-harming behavior, concluding it was not of unknown source.
A resident with dementia and a history of wandering eloped from the facility after a CNA improperly used an emergency exit door, which was not equipped with a wander guard alarm. The CNA manually closed the door, causing it not to latch correctly, allowing the resident to leave unnoticed. The facility's policies for elopement risk and security systems were not effectively implemented.
A resident with a history of neurogenic bladder was readmitted to the facility with a Foley catheter, but the facility failed to conduct a voiding trial or arrange a urology consult as recommended. Despite previous successful catheter removal, staff did not reassess the necessity of the catheter upon the resident's return, leading to a deficiency in care. Interviews revealed a lack of documentation and awareness among staff regarding the resident's catheter status and the need for follow-up care.
A resident with osteomyelitis received long-term Augmentin without proper monitoring or follow-up, revealing a deficiency in the facility's antibiotic stewardship program. The facility failed to track the antibiotic use, lacked documentation of its necessity, and did not ensure follow-up with an Infectious Disease Physician, as recommended.
Elopement of High-Risk Resident Through Delayed Egress Door Without Adequate Alarm Response
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance devices to prevent an elopement for one resident with severe cognitive impairment and known exit-seeking behaviors. The resident had dementia, chronic kidney disease, seizures, severe cognitive impairment, behavioral symptoms, rejection of care, and wandering behaviors documented on the MDS. The comprehensive care plan identified the resident as at risk for elopement related to confusion and dementia, with an intervention for use of a wander detection/monitoring device on the right ankle and a goal that the resident would remain on the premises. Additional documentation, including the Kardex and a Nursing Elopement Risk Data Collection Tool, showed the resident was independent with a rolling walker, had a history of unsafe wandering, opening outside doors, elopement, and making statements about leaving or seeking someone/something. On the day of the incident, progress notes documented that the resident wandered throughout the shift, repeatedly called for help, expressed fear, and showed increased anxiety, with 1:1 support, food, drink, and toileting having no effect. The LPN supervisor reported that the resident had been following them around and was anxious, and that they last saw the resident between 9:15 PM and 9:30 PM, assuming staff had assisted the resident to bed. A CNA reported that around 9:00 PM they assisted the resident to bed after the resident asked for help. Despite the resident’s known elopement risk and active exit-seeking history, the resident was able to push on the delayed egress front door and exit the facility at 9:41 PM without staff knowledge. Video surveillance showed the resident exiting through the delayed egress front door, and a CNA responding to the door alarm at 9:43 PM. The CNA stated they heard the alarm, went to the front entrance, looked into the entryway, did not see anyone, turned the alarm off, and reactivated the system without opening the exterior doors or checking outside, and did not notify the nursing supervisor of the alarm. The facility’s policies on elopement and security system alarms required staff to respond to alarms, ensure residents did not elope, and follow an organized plan to locate missing residents. However, no staff reported the alarm activation to the supervisor, and the LPN supervisor stated they were unaware the resident had exited until emergency services arrived and reported the resident was across the street in a parking lot. A police report documented that a caller found a confused elderly person at a nearby restaurant after a bystander had seen the person ambulating with a walker along a state highway and transported them to the restaurant parking lot, where emergency medical services identified the individual as having left the facility.
Removal Plan
- Assess resident for injuries.
- Update the resident care plan to include 1:1 staff supervision.
- Replace the delayed egress locking system on the front door with a wander guard locking system to keep the door secure unless a code is entered.
- Evaluate other exit doors and replace with a Mag Lock system.
- Ensure the resident has a wander alert device in place that works in conjunction with the wander guard locking system at the front door.
- Educate staff on elopement/resident safety and expectations when an alarm is activated.
- Conduct missing person drills.
- Conduct audits to monitor compliance with response to alarms and alerts.
Inadequate Infection Control Practices and Scabies Outbreak Management
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, leading to the potential spread of communicable diseases among residents. Specifically, staff did not adhere to enhanced barrier precautions for residents with indwelling medical devices or active infections. For instance, a registered nurse did not wear a gown while providing care to a resident with a peripherally inserted central catheter and scabies, despite clear signage indicating the need for contact precautions. Additionally, a licensed practical nurse administered medication to the same resident without using personal protective equipment, further violating infection control protocols. The facility also neglected to implement enhanced barrier precautions for residents with indwelling urinary catheters. Two residents with foley catheters did not have appropriate signage or personal protective equipment available outside their rooms, and staff were observed not wearing gowns while performing catheter care. Interviews with staff revealed a lack of understanding and inconsistent application of enhanced barrier precautions, with some staff believing that such precautions were unnecessary for residents with contained urine or inactive infections. Furthermore, the facility's infection preventionist failed to adequately track and manage an outbreak of scabies. Although two residents were confirmed positive for scabies, the facility did not maintain a comprehensive list of staff who had contact with these residents. The infection preventionist acknowledged the importance of tracking potential exposures but admitted to confusion and incomplete contact tracing efforts. This oversight hindered the facility's ability to effectively manage and contain the outbreak, as confirmed by the regional epidemiologist and medical director.
Inadequate Investigation of Resident Injury
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged violation of abuse and neglect for a resident with severe cognitive impairment and multiple medical conditions, including dementia and spinal stenosis. The resident, who was non-ambulatory and required maximal assistance for transfers and personal hygiene due to combative behavior, was found with a bruise below the right eye. The facility's policy required an immediate and thorough investigation of injuries of unknown source, including interviews and statements from staff who worked the previous two shifts, to rule out abuse or neglect. Despite the policy, the investigation into the resident's injury lacked interviews and statements from staff who worked the previous two shifts. The Director of Nursing concluded that the injury was not of unknown source, attributing it to the resident's known combativeness and self-harming behavior. The Director of Nursing and the Administrator both believed that the injury was likely self-inflicted due to the resident's behavior, and therefore did not consider it necessary to conduct further interviews or gather additional witness statements. The failure to conduct a comprehensive investigation, as outlined in the facility's policy, resulted in a deficiency. The lack of staff interviews and statements from the previous shifts meant that the investigation did not fully adhere to the required procedures for ruling out abuse or neglect, despite the facility's belief that the injury was self-inflicted due to the resident's combativeness.
Resident Elopement Due to Improper Use of Emergency Exit
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident at risk of elopement. The resident, who was diagnosed with dementia and depression, was severely cognitively impaired and had a history of wandering behaviors. Despite being identified as a risk for elopement and having a wander guard alarm in place, the resident managed to leave the facility without staff knowledge and was outside for 20 minutes. The incident occurred when a Certified Nurse Assistant (CNA) exited through an emergency exit door, which was not equipped with a wander guard alarm. The CNA manually closed the door, causing it not to latch correctly, allowing the resident to push it open and leave the facility. The CNA was unaware of the resident's presence behind them and did not see the resident exit the building. The door was supposed to be checked every shift to ensure it was locked, but the CNA had obtained the door code from another employee and used it to exit the building improperly. The Director of Nursing and the Administrator were unaware of the resident's elopement until the resident was found outside by a family member. The facility's policies and procedures for elopement risk, missing residents, and security systems were not effectively implemented, leading to the resident's unsupervised exit. The CNA involved was an agency employee and no longer worked at the facility following the incident.
Failure to Conduct Voiding Trial and Urology Consult for Resident with Foley Catheter
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a deficiency. Resident #37, who had a history of hemiplegia, type 2 diabetes, and major depressive disorder, was readmitted to the facility from the hospital with a Foley catheter. The resident's comprehensive care plan indicated the presence of a urinary catheter due to neurogenic bladder, with interventions including catheter care every shift. However, upon readmission, the facility did not conduct a voiding trial to assess the necessity of the catheter, nor did they arrange for a urology consult as recommended in the hospital discharge summary. The resident had previously been admitted to the hospital with severe sepsis, believed to be secondary to a urinary tract infection associated with the chronic use of a Foley catheter. Despite the medical director's order for a voiding trial upon the resident's return in April, which was successfully completed, the facility failed to repeat this process when the resident was readmitted in June. Interviews with staff revealed a lack of awareness and documentation regarding the necessity of the catheter and the absence of a urology consult, which contributed to the oversight. The deficiency was further highlighted during interviews with the resident and various staff members, including the LPN, RN Resident Care Coordinator, Infection Preventionist/DON, and MDS Coordinator. The resident expressed concerns about the prolonged use of the catheter and a recent urinary tract infection. The staff interviews revealed confusion and miscommunication regarding the resident's catheter status and the need for a voiding trial, ultimately leading to the failure to provide appropriate catheter management and follow-up care.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure an effective antibiotic stewardship program for a resident diagnosed with osteomyelitis, who had been receiving the antibiotic Augmentin since July 2023. The program lacked protocols for monitoring antibiotic use, including communication, tracking, and appropriate indications for continued use. There was no follow-up appointment with an Infectious Disease Physician as recommended, and the comprehensive care plan did not document the antibiotic use for osteomyelitis. The resident, who was cognitively intact, had a history of sacral osteomyelitis and a stage 4 pressure ulcer. Despite recommendations from an infectious disease consult to monitor lab results monthly and schedule a follow-up appointment, there was no evidence of such monitoring or follow-up. The facility's records, including the Order Summary Report and Medication Administration Record, showed continuous administration of Augmentin without a stop date or documented rationale for its continued use. Interviews with facility staff revealed that the Director of Nursing/Infection Preventionist did not track the resident's long-term antibiotic use, as they only monitored acute antibiotic use. The Pharmacy Consultant confirmed that all antibiotics should be tracked, but the facility had not requested a monthly antibiotic report. The Medical Doctor involved expected the facility to follow protocol but could not confirm any follow-up consults with infectious disease specialists. The lack of monitoring and documentation led to the deficiency identified by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gasport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elderwood At Lockport | 4.9 mi | ★★★★★ | 1 | 0 |
| Lockport Rehab & Health Care Center | 5.7 mi | ★★★★★ | 13 | 0 |
| Newfane Rehab & Health Care Center | 8.8 mi | ★★★★★ | 0 | 0 |
| Medina Memorial Hospital Snf | 9.1 mi | ★★★★★ | 0 | 0 |
| Orchard Rehabilitation & Nursing Center | 10.3 mi | ★★★★★ | 2 | 0 |
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