Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 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.
The facility failed to ensure the DON only worked as a charge nurse when census was 60 or below. Staffing records showed DONs were counted to meet minimum staffing and worked charge nurse shifts while census was 76, 77, and 80. Interviews confirmed the facility relied on the DON to cover shortages after trying per diem, agency, and other staff, and the Administrator acknowledged awareness of the rule but said there were not enough RNs.
Food and beverages were served at suboptimal temperatures and were often described as bland, cold, watery, or unappetizing. Surveyors observed test trays in the dining room and on unit meal carts with hot items such as ham, rice, vegetables, chili, spinach, and coffee measuring below preferred serving temperatures, and staff acknowledged that some items were too cool and that trays were delivered late or held too long. Residents reported cold meals, cold coffee, mushy vegetables, tough meat, and poor overall palatability.
A facility failed to complete PASRR Level I screens before admission for two residents. One resident had bipolar disorder, anxiety, and depression and was cognitively intact, while the other had dementia with agitation, major depressive disorder, and moderate cognitive impairment with behavioral symptoms. Staff could not locate the PASRRs, and interviews showed the admission paperwork was accepted without verifying the required screens were present.
Air Mattress Not Functioning for Resident With Multiple Pressure Ulcers. A resident with osteomyelitis, a stage 4 sacral PU, and bilateral stage 3 PUs had an air/foam mattress ordered for pressure reduction, but staff repeatedly observed the hose disconnected and the pump unplugged, so the air mattress was not functioning. Records showed no documented monitoring of the mattress function or settings, and staff interviews confirmed they were unaware the mattress was not operating properly.
Failure to use EBP during wound care and update Legionella plan: An LPN provided wound care to a resident with diabetes, PVD, and chronic wounds while wearing gloves but no gown, despite signage requiring gown and glove use for wound care. Staff interviews confirmed the resident should have been on EBP and that gowns were expected for wound care. The facility also could not show that its Legionella Water Management Plan had been reviewed or revised annually, with leaders stating the most recent version was from 2023.
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.
DON Worked Charge Nurse Shifts Above Allowed Census
Penalty
Summary
The facility failed to ensure the Director of Nursing (DON) served as a charge nurse only when the average daily occupancy was 60 residents or fewer. Record review showed that both DON #1 and DON #2 were counted in staffing and worked charge nurse shifts when the census was above 60, including when the resident census was 76, 77, and 80. The facility’s staffing plan, daily staffing sheets, and daily schedule reports showed the DONs were used to meet minimum staffing requirements for direct resident care and overnight coverage. The facility documents described the DON’s role as directing nursing services and maintaining adequate staffing, while the facility policy on daily staffing stated that minimum critical staffing levels would be addressed in the facility assessment and that the Nursing Supervisor was to contact the DON and/or Administrator when staffing fell below minimum levels. The facility assessment listed day, evening, and overnight staffing needs, including multiple RNs, LPNs, and CNAs. Despite this, the staffing sheets and schedules showed DON #1 worked as a charge nurse on one overnight shift and another evening-to-day shift, and DON #2 worked as a DON during the day and then returned for an overnight charge nurse shift. Interviews confirmed that staffing shortages led the facility to rely on the DONs to fill shifts. The Staffing Coordinator stated they would first try per diem staff, agency staff, and other staff before using the DON, but they still relied on the DON when needed. DON #1 stated they worked as a supervisor when minimum staffing could not be met and were not aware of the rule limiting DON charge nurse work to census of 60 or below. The Administrator stated they were aware of the regulation but said they had no choice because they did not have enough RNs. The Corporate Clinical Director stated the DON could not work any additional role simultaneously during the 40-hour work week, though additional shifts could be picked up beyond that.
Food Served at Improper Temperatures and Poor Quality
Penalty
Summary
Food and drink were not served at palatable, attractive, and safe appetizing temperatures for residents eating in the Heritage unit, Main Dining Room, and Woodland Heights unit. The facility policy required hot foods to be held and served hot and cold foods cold, with dining locations maintaining food at proper temperatures and out of the danger zone. During the survey, residents across multiple units reported that meals were often cold, bland, late, mushy, overcooked, greasy, or otherwise unappealing. Residents also reported cold coffee, dry or tough meat, and delayed tray delivery to rooms. Surveyors observed and measured multiple test trays and steam table items. In the main kitchen, several hot foods were measured at temperatures such as 135, 140, 150, 160, and 180 degrees Fahrenheit, and the dietary staff stated ideal hot holding temperatures were between 145 and 150 degrees Fahrenheit. On the Heritage unit, the test tray arrived after the cart had been on the unit and the meal items were measured at 115 degrees Fahrenheit for steamed spinach and 140 degrees Fahrenheit for chili; the spinach was described as watery, slightly warm, and flavorless, and the meal did not look attractive. In the Main Dining Room, the test tray items measured 115 degrees Fahrenheit for ham, 90 degrees Fahrenheit for rice, and 110 degrees Fahrenheit for vegetables, and the Director of Dietary described the rice as bland and cold and the vegetables as bland and needing to be warmer. On Woodland Heights, the test tray items measured 112 degrees Fahrenheit for ham, 114 degrees Fahrenheit for vegetables, and 124 degrees Fahrenheit for coffee. The vegetables were described as watery, flavorless, and lukewarm, and the coffee was warm rather than hot. The Evening Dietary Supervisor stated the food temperatures should have been higher and that the trays for Woodland Heights were the last to be served, with lids removed during serving. The Corporate Clinical Director stated they were unsure of the safe temperature ranges for food service, while the Director of Dietary stated hot foods should be served between 145 and 155 degrees Fahrenheit and cold foods at 38 degrees Fahrenheit or lower.
Missing PASRR Screens Before Admission
Penalty
Summary
The facility failed to ensure a PASRR Level I identification screen was completed before admission for two residents. The facility policy required a screen for every resident prior to admission regardless of length of stay, and the admission process policy stated all residents must have a completed screen showing the minimum qualifications for admission were met. For one resident, the record showed diagnoses including bipolar disorder, anxiety, and depression, and the MDS documented the resident was cognitively intact and always understood and understood others. Review of the medical record showed the resident was admitted without any Level I PASRR present before the admission date. For the second resident, the record showed diagnoses including dementia with agitation, major depressive disorder, and polyosteoarthritis, and the MDS documented moderate cognitive impairment with behavioral symptoms. Review of the electronic medical record showed the resident was admitted without evidence of a Level I preadmission screening form before the admission date. During interviews, the Social Worker stated they could not locate the PASRR for either resident, and for one resident noted the screen was missing despite the resident’s bipolar disorder diagnosis. The Administrator stated the person accepting admission paperwork should have reviewed it and ensured the screens were present, and that the screen was important to determine whether residents required more services.
Air Mattress Not Functioning for Resident With Multiple Pressure Ulcers
Penalty
Summary
The facility failed to ensure that Resident #3, who had diagnoses including osteomyelitis, a stage 4 sacral pressure ulcer, spinal stenosis, and two stage 3 pressure ulcers, received necessary treatment and services consistent with professional standards of practice to promote healing. The resident’s Minimum Data Set documented substantial to dependent assistance with bed mobility and identified the resident as at risk for pressure ulcers, with pressure ulcers present on admission. The care plan and Kardex identified the use of a pressure reduction device for bed, specifically an air mattress set to 238 pounds, and the order summary included every 2-hour offloading while in bed for skin integrity. Record review showed the treatment administration records from 01/01/2026 through 05/27/2026 contained no documented evidence regarding the use or monitoring of the air/foam mattress’s function and settings. A wound care consultation documented the sacral/coccyx stage 4 ulcer and bilateral buttock stage 3 ulcers, with the healing status of all ulcers described as plateau/stalled. Weekly skin status documentation also showed the wounds remained present and measured larger than in the wound consult. The consultation recommended use of a pressure redistribution device. During multiple observations, the resident was in bed with the air mattress hose disconnected from the pump and the pump unplugged and hanging from the foot board, preventing air flow to the mattress. During wound care, the air mattress pump was still not connected or functioning. Staff interviews showed the CNA recognized the resident should have an air mattress and that it was not blowing air, while an LPN and the resident care coordinator were unaware the mattress was not functioning properly. The DON stated staff were expected to check that air mattresses were functioning and notify maintenance if they were not, and maintenance later confirmed the hose was disconnected and the pump was unplugged until they reconnected and turned it on.
Failure to Use EBP During Wound Care and Update Legionella Plan
Penalty
Summary
The facility failed to maintain an infection prevention and control program when staff did not use the required personal protective equipment during wound care for a resident on enhanced barrier precautions. The resident had diagnoses including diabetes, ulceration of the left leg, and peripheral vascular disease, and was cognitively intact. The resident also had a Stage III pressure ulcer and a vascular wound, and the care plan identified infection risk related to wounds with interventions including enhanced barrier precautions and monitoring for signs of infection. During wound care observation, an LPN completed treatment to the resident’s left buttock pressure ulcer and left pinky toe vascular ulcer while wearing gloves but not a gown. Enhanced barrier precaution signage was posted on the room door frame and indicated that gloves and a gown were required for high-contact care activities, including wound care. After the observation, the LPN stated they did not think a gown was required because they believed the sign applied only to the roommate, then acknowledged the sign applied to both residents in the room and that they should have worn a gown. The resident care coordinator stated that every resident with a wound was to be on enhanced barrier precautions and that staff were to wear gowns when performing wound care. The wound consultant stated the resident’s buttock wound was usually moist and that they wore gowns during their rounds because it was safer to do so. The corporate clinical director stated that if staff were providing care to residents with open areas such as wounds, staff were expected to wear gloves, gowns, and masks. The facility also failed to ensure its Legionella Water Management Plan was reviewed or revised annually. The facility’s Legionella documents included an environmental assessment dated 07/07/2025 and a sampling and management plan effective 10/31/2023, which listed a former administrator as the point of contact and a former director of nursing/infection preventionist as the infection control team member. The director of maintenance, DON, and administrator all stated they were not sure the plan had been reviewed or revised since 2023, and the administrator stated they had not personally reviewed it and could not locate documentation showing it had been reviewed or revised since October 2023.
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 | ★★★★★ | 0 | 0 |
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