Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Buffalo Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A CNA verbally and mentally abused a cognitively impaired, incontinent resident by yelling in a harsh, demeaning tone and making threats about moving the resident to another floor. The resident became tearful and expressed distress after the incident. Staff interviews confirmed the behavior was inappropriate and constituted abuse, with the resident unable to control their actions due to medical conditions.
A resident with severe cognitive and physical impairments, care planned for two-person assist with bed mobility, was provided care by a single CNA who was aware of the requirement. During incontinence care, the resident rolled out of bed, sustaining a complex facial laceration and eye injury that required hospital transfer and surgical repair. Staff interviews confirmed the care plan was not followed, resulting in actual harm.
A resident with complex medical needs and their legal representative were not provided timely access to medical records after submitting a written HIPAA authorization. Delays occurred due to staff being unavailable, lack of follow-up, and unfamiliarity with the release policy, resulting in the records never being released as required.
A resident with significant cognitive and physical impairments was the subject of an abuse allegation communicated to facility leadership by the resident's Health Care Proxy Agent. The allegation, involving verbal threats and physical mistreatment by a CNA, was not reported to the New York State Department of Health within the required two-hour timeframe, as facility policy and state regulations mandate. Both the DON and Administrator confirmed the failure to recognize and report the allegation promptly.
A resident with severe cognitive impairment and multiple disabilities was the subject of an abuse allegation reported by their Health Care Proxy Agent. The allegation, which included verbal threats and physical mistreatment by a CNA, was communicated to the Administrator via email. The Administrator failed to recognize and investigate the abuse claim, and the DON was not informed, resulting in no investigation being conducted as required by facility policy.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not manage its operations in a way that ensured effective and efficient use of its resources, as identified by surveyors.
Staff failed to immediately report suspected abuse after images of several residents in various stages of undress were posted on social media by a CNA, showing them in soiled conditions. Despite being aware of the incident within an hour, facility leadership did not notify the State Agency or law enforcement as required, instead treating the matter as a dignity concern and delaying official reporting.
Following a social media post containing photos of residents in various stages of undress and allegations of inadequate care, the facility did not conduct a thorough investigation as required by policy. The investigation lacked comprehensive staff and resident interviews, did not include all affected individuals, and focused primarily on dignity rather than abuse, resulting in incomplete documentation and failure to fully address the allegations.
A staff altercation involving yelling and the throwing of objects occurred in a resident lounge area, witnessed by several cognitively impaired residents. The incident was recorded by a staff member on a cell phone and posted on social media, displaying residents in the background. This violated facility policies on dignity, resident rights, and cell phone use, as well as HIPAA privacy regulations. Staff and management acknowledged the event was unprofessional and disrespectful to residents.
A resident with severe cognitive impairment and mobility dependence developed a bruise and later a protrusion on the left shoulder, which was ultimately diagnosed as a fractured clavicle. Despite facility policy requiring investigation of injuries of unknown origin, staff did not initiate a new investigation, assuming the injury was related to a previously documented bruise. No RN assessment was performed at the time, and the incident was not reported to the DON or Administrator as required.
The facility failed to maintain safe hot water temperatures, with readings exceeding the policy range on all resident use floors. Multiple residents and staff reported excessively hot water, and the Maintenance Director acknowledged the issue, citing recent pump replacement and thermostat adjustments. The facility lacked documentation of temperature checks during the Maintenance Director's absence, leading to unsafe conditions.
The facility failed to involve a licensed pharmacist in all aspects of pharmacy services and did not maintain proper records for controlled drugs. Discontinued narcotics were stored without accountability, and shift-to-shift narcotic counts were not consistently signed off. The Pharmacist Consultant was not involved in the controlled substance processes.
A resident with sepsis, chronic pancreatitis, and dementia did not receive weekly blood tests as recommended, and there was no care plan for the use of an IV midline catheter. The oversight was due to a lack of communication and proper follow-up among staff.
Verbal and Mental Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) verbally and mentally abused a resident with severe cognitive impairment and urinary incontinence. The resident, who had diagnoses including encephalopathy, obstructive hydrocephalus, and intracerebral hemorrhage, was observed urinating on themselves and their surroundings. The CNA, appearing frustrated, loudly expressed annoyance in the hallway and then entered the resident's room, yelling at the resident in a harsh, demeaning tone and threatening that the resident would be moved to another floor. The CNA's language and demeanor were hostile, impatient, and dismissive, and the incident was witnessed by another CNA and later reported to the social worker and nursing supervisor. Following the encounter, the resident became tearful, appeared saddened, and communicated that they did not like being yelled at by staff. Interviews with staff, including the CNA involved, other CNAs, the social worker, nursing supervisors, and the administrator, confirmed that the CNA's actions constituted verbal and mental abuse. Staff acknowledged that the resident could not control their incontinence due to their medical condition and that the CNA's behavior was inappropriate and could cause psychosocial harm. The facility's policy prohibits such mistreatment, and the incident was recognized as a violation of resident rights to dignity and respect. The investigation concluded that there was reasonable cause to believe that abuse had occurred, as the CNA's actions met the definitions of verbal and mental abuse outlined in facility policy. The incident was reported to the appropriate personnel, and the resident was monitored for psychosocial effects. The deficiency was determined to have caused psychosocial harm to the resident, as evidenced by their emotional response and statements following the event.
Failure to Provide Required Two-Person Assist Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, right-sided hemiplegia and hemiparesis, and severe cognitive impairment was not provided with the required level of assistance for bed mobility as outlined in their comprehensive care plan. The care plan and Kardex specified that the resident was dependent on two or more staff members for bed mobility, including rolling in bed and toileting hygiene, due to their high risk for falls and inability to carry out activities of daily living independently. On the day of the incident, a certified nurse aide (CNA) provided incontinence care to the resident without the assistance of a second staff member, despite being aware of the care plan requirements. During the care, the resident rolled out of bed and sustained a multilayered facial laceration and swelling to the left eye. The CNA attempted to prevent the fall but was unable to do so alone. The resident was subsequently transferred to the hospital, where they required surgical repair of the facial laceration and additional medical evaluation. Interviews with facility staff, including the CNA involved, the former Registered Nurse Manager, and administrative personnel, confirmed that the care plan was not followed at the time of the incident. The staff acknowledged that the resident required a two-person assist for bed mobility and that failure to adhere to this protocol resulted in the resident's fall and injury. The incident was recognized as causing actual harm to the resident, though it was not classified as Immediate Jeopardy.
Failure to Timely Release Resident Medical Records
Penalty
Summary
The facility failed to provide a resident and their legal representative with access to or copies of the resident's medical records within the required timeframe, despite a written request and proper authorization. The resident, who was cognitively intact and had significant medical conditions including a CRE infection, rectal cancer, and a colostomy, completed the necessary HIPAA authorization form to release their records to their Health Care Proxy. The facility's policy required that such requests be honored within 48 hours (excluding weekends and holidays) upon receipt of a written request. After the request was submitted, the process was delayed at multiple points. The Medical Records staff sent the authorization to Risk Management, which approved the release pending review by the DON. However, Medical Records did not forward the records for review until several days later, citing being off or occupied with other work. Complicating matters, the DON was no longer employed at the facility at the time, so the records were sent to the prior Administrator, but there was no follow-up or confirmation that the records were reviewed or released. As a result, the records were never provided to the resident or their representative. Interviews with staff revealed a lack of familiarity with the facility's policy on releasing medical records and a breakdown in communication and follow-up. Medical Records staff admitted they did not know the policy details and did not ensure the request was completed. The prior Administrator stated they would have expected to be notified sooner and that there should not have been a delay. Ultimately, the resident's request for their medical records was not fulfilled as required by facility policy and regulatory standards.
Failure to Timely Report Alleged Resident Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and mistreatment were reported immediately, but not later than two hours after the allegation was made, as required by regulation. Specifically, an allegation of verbal, mental, and physical abuse against a resident with cerebral palsy, intellectual disability, and dysphagia was communicated to the facility's Administrator via email from the resident's Health Care Proxy Agent. The email described an incident in which a Certified Nurse Aide allegedly yelled at the resident, threatened to withhold food, and stepped on the resident's foot. Despite the facility's policy requiring immediate reporting of such allegations to the New York State Department of Health, there was no evidence that this was done within the required timeframe. Record review and staff interviews revealed that the Director of Nursing was not aware of the abuse allegation until it was brought to their attention during the survey, and the Administrator acknowledged having missed the allegation in the email correspondence. The facility's documentation did not show that the abuse allegation was reported to the appropriate authorities as mandated, resulting in noncompliance with state regulations regarding the timely reporting of suspected abuse.
Failure to Investigate Alleged Abuse Reported by Resident's Proxy
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with cerebral palsy, intellectual disability, and dysphagia, who was cognitively severely impaired and required assistance with activities of daily living. The resident's Health Care Proxy Agent sent an email to the Administrator describing an incident in which a Certified Nurse Aide allegedly yelled at the resident, threatened to withhold food, and stepped on the resident's foot, which was characterized as abuse. Despite receiving this email, the Administrator did not recognize or act upon the abuse allegation, and the Director of Nursing was not informed of the incident. A review of facility policies indicated that all allegations of abuse are to be promptly reported and thoroughly investigated, including notifying the DON and Administrator-on-call, and conducting interviews with involved parties. However, documentation provided by the Administrator did not show evidence of an investigation into the abuse allegation. Interviews with facility leadership confirmed that the required investigation was not initiated, as the Administrator overlooked the abuse allegation in the email correspondence.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all residents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standard for resource management. Specific actions or inactions leading to this deficiency are not detailed in the report provided.
Failure to Timely Report Suspected Abuse Involving Social Media Posts
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and mistreatment were reported immediately, but not later than two hours after the allegation was made, to the appropriate authorities, including the State Survey Agency and local law enforcement. This deficiency was identified for four residents, all of whom were depicted in photographs posted on social media by a Certified Nurse Aide. The photographs showed residents in various stages of undress, with their buttocks and genitalia exposed, and indicated that the residents had not received proper care. The social media post was publicly shared numerous times, and the incident was not initially reported by the facility. The residents involved had a range of medical and cognitive conditions, including generalized anxiety disorder, major depressive disorder, selective mutism, morbid obesity, chronic kidney disease, hypothyroidism, encephalopathy, polyneuropathy, anemia, cerebral infarction, hemiplegia, and hemiparesis. Some residents were cognitively intact, while others had severe cognitive impairment. The facility's own policy required immediate reporting of suspected abuse, but the Administrator and Director of Nursing did not recognize the incident as abuse at the time, instead viewing it as a dignity concern and beginning an internal investigation without notifying authorities. Despite being made aware of the social media post within an hour, the facility did not report the incident to the State Agency or law enforcement until several days later, after the recertification team brought the issue to their attention and questioned whether it constituted abuse. Interviews with staff confirmed that the images could be humiliating and degrading for the residents, and that such incidents should be reported as suspected abuse within the required timeframe.
Failure to Thoroughly Investigate Alleged Abuse and Neglect Following Social Media Incident
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and neglect for four residents following a social media post that included photographs of residents in various stages of undress and allegations of inadequate care. The facility's own policies required prompt and comprehensive investigations, including interviews and written statements from staff, residents, and families who might have relevant information. However, the investigation lacked key elements such as staff witness statements regarding the social media post, interviews with all potentially involved staff, and inclusion of all affected residents, specifically omitting one resident entirely from the investigation process. The investigation primarily focused on dignity concerns rather than abuse, as indicated by the actions of the Administrator and DON. Resident interviews were limited to a standard dignity worksheet that did not address the specific issues of abuse, use of cell phones, or unauthorized photography. Some residents expressed concerns about their care, but there was no documented follow-up. Additionally, not all residents or their responsible parties were interviewed, and there was no evidence that families were informed or questioned about the incident, despite the public nature of the social media post. Staff interviews were incomplete, with only select CNAs providing written statements based on assignment sheets, and other staff who may have had relevant information were only spoken to informally without documentation. The facility leadership acknowledged that the investigation was general due to an inability to identify all residents in the photographs, and they did not consider the incident as abuse. The lack of comprehensive interviews, documentation, and inclusion of all potentially affected individuals led to an incomplete investigation, contrary to facility policy and regulatory requirements.
Staff Altercation and Social Media Posting Violates Resident Dignity and Privacy
Penalty
Summary
A deficiency occurred when an altercation between staff members took place in a resident care area, in the presence of residents. The incident involved yelling, screaming, and the throwing of objects between a Licensed Practical Nurse and a Certified Nurse Aide, with other staff and residents present in the lounge area near the nurse's station. The event was chaotic and undignified, as described by staff, and was witnessed by at least three residents, all of whom had varying degrees of cognitive impairment and diagnoses such as anxiety, multiple sclerosis, Alzheimer's disease, depression, and diabetes. The altercation was recorded on a cell phone by a staff member and subsequently posted on social media, which included images of the residents present during the incident. This action violated the facility's policies on quality of life, dignity, resident rights, and cell phone use, as well as HIPAA privacy regulations. Staff interviews confirmed that the use of cell phones in resident areas and the sharing of such videos were prohibited and considered disrespectful and a breach of privacy. Interviews with staff and residents indicated that the fight was inappropriate, disrespectful, and created an environment that was not conducive to the dignity and respect of the residents. While some residents could not recall the incident, staff and management acknowledged that the event was unprofessional and likely made residents feel uncomfortable, frightened, and confused. The presence of residents in the video posted online further compounded the violation of their rights and privacy.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident with severe cognitive impairment and a history of Alzheimer's disease and dysphagia. The resident was dependent on staff for mobility and required assistance with activities of daily living. The care plan indicated the resident had impaired cognition and limited physical mobility. During routine rounds, staff discovered bruising on the resident's left arm and shoulder, and the medical director was notified, resulting in discontinuation of a blood thinner and therapy orders. Subsequent documentation showed that the resident had decreased mobility and, later, a protrusion within the bruised area on the left shoulder, which caused pain. The resident was medicated for pain and then transported to the hospital, where a fractured clavicle was diagnosed. Despite these findings, no new incident report or investigation was initiated for the injury of unknown origin. Staff interviews revealed that the presence of a previous bruise led to the assumption that the new injury was related, and therefore, no further investigation was conducted. There was also no Registered Nurse assessment at the time, as none were on duty. Interviews with facility staff, including LPNs, the DON, and the Administrator, confirmed that an investigation was not started because the injury was considered part of a previously investigated bruise. The facility's policies required investigation of all injuries of unknown origin, but this was not followed. The Medical Director stated that an investigation should have been completed for such an injury. The lack of a thorough investigation was contrary to facility policy and regulatory requirements.
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility did not ensure that the residents' environment remained as free from accident hazards as possible, specifically regarding hot water temperatures. Observations on four resident use floors revealed water temperatures exceeding the facility's policy range of 105 to 120 degrees Fahrenheit, with temperatures recorded as high as 135.7 degrees Fahrenheit. Multiple residents and staff reported that the water was too hot, and some residents had to adjust the temperature by adding cold water. The Maintenance Director acknowledged the issue and stated that the facility had recently replaced a pump, which improved hot water circulation, and they had been adjusting the hot water system's thermostat since then. However, there was a lack of documentation of hot water temperatures during the Maintenance Director's absence, and no other maintenance staff had checked the temperatures during this period. Interviews with various staff members, including housekeepers, certified nurse aides, and licensed practical nurses, confirmed that the hot water was hotter than usual, and some staff had to mix it with cold water to prevent scalding. The Maintenance Director admitted that the hot water system's thermostat was set too high and that the facility lacked a mixing valve to regulate the temperature. Additionally, the Maintenance Director's infrared thermometer, used to measure water temperatures, had not been calibrated since its purchase two months prior. The facility's maintenance log showed that hot water temperatures were recorded daily on weekdays, but there were no entries for the period when the Maintenance Director was out of town. The Administrator stated that the expectation was for maintenance staff to check hot water temperatures daily, even in the Maintenance Director's absence. However, this did not occur, leading to excessively high water temperatures in resident areas. The deficiency was identified through observations, interviews, and record reviews conducted during the standard survey, highlighting the facility's failure to maintain a safe environment for residents by not adequately monitoring and controlling hot water temperatures.
Failure to Maintain Proper Narcotic Accountability and Involvement of Licensed Pharmacist
Penalty
Summary
The facility failed to obtain the services of a licensed pharmacist involved with all aspects of pharmacy services, and did not establish a system of records for the receipt and disposition of all controlled drugs. Specifically, the discontinued narcotic storage closet in the Assistant Director of Nursing's office lacked accountability records for narcotics awaiting destruction. Additionally, narcotic reconciliation drug records on several wings were not consistently signed off as completed. The Pharmacist Consultant confirmed they were not involved with the controlled substance processes in the facility. During an observation, it was noted that the discontinued narcotic medications were stored in a closet with a double lock, containing an excessive number of narcotics without proper accountability. Various storage methods were used, including a locked safe, cardboard boxes, and a green bag, many of which lacked corresponding account logs. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that there was no accountability for the narcotics at the time of key exchanges, and the process for logging discontinued narcotics was not followed as per the facility's policy. Further observations and interviews with LPNs revealed that shift-to-shift narcotic counts were not consistently signed off, with multiple instances of missing signatures in the narcotic reconciliation books. The LPNs admitted to being too busy or distracted to sign the shift count sheets, and some even counted narcotics alone when the off-going nurse had already left. The Director of Nursing and the Regional Director of Clinical Services acknowledged the lack of adherence to the policy and the importance of maintaining accurate logs for accountability and to prevent narcotic diversion.
Failure to Ensure Weekly Blood Tests and Care Plan for IV Catheter
Penalty
Summary
The facility did not ensure that Resident #63 received treatment and care in accordance with professional standards of practice. Specifically, the resident did not have weekly blood tests completed as recommended per the hospital discharge summary and the facility Medical Director. Additionally, there was no care plan developed for the use of an intravenous midline catheter, which was necessary for the delivery of medications and/or fluids. The resident had diagnoses including sepsis, chronic pancreatitis, and dementia, and was understood to have severe cognitive impairment. Despite the hospital discharge summary and multiple progress notes from the Medical Director and Physician Assistant indicating the need for weekly c-reactive protein tests and erythrocyte sedimentation rates, these tests were not ordered or completed until 5/5/24, well after the resident's admission on 3/27/24. The failure to order these tests was attributed to a lack of communication and oversight among the staff responsible for transcribing and following up on the orders. The Unit Clerk, who was responsible for filing out laboratory sheets, was not informed about the need for these specific tests. The Medical Director and Licensed Practical Nurse involved in the resident's care both acknowledged the oversight, with the LPN admitting to erroneously omitting the blood work recommendation. Furthermore, the Director of Nursing confirmed that there was no care plan developed for the resident's intravenous catheter, which was against the facility's policy and procedure for comprehensive care plans.
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What surveyors actually found near you
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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 Buffalo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Delaware Oaks Center For Rehabilitation And Nursin | 0.4 mi | ★★★★★ | 2 | 0 |
| Highpointe On Michigan Health Care Facility | 0.8 mi | ★★★★★ | 2 | 0 |
| Humboldt House Rehabilitation And Nursing Center | 1.3 mi | ★★★★★ | 28 | 1 |
| Ellicott Center For Rehabilitation And Nursing | 1.5 mi | ★★★★★ | 0 | 0 |
| St Catherine Laboure Health Care Center | 1.7 mi | ★★★★★ | 5 | 0 |
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