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 Degraff Memorial Hospital-skilled Nursing Facility during CMS and state inspections, most recent first.
Two nurse aide trainees witnessed a certified nurse aide physically and verbally abuse a resident but delayed reporting the incident for two days due to uncertainty about the process and fear of job loss. The incident was eventually reported up the chain of command, resulting in the administrator and state health department being notified outside the required timeframe. The resident, who was dependent on staff and had multiple diagnoses, did not report or show signs of abuse when later interviewed.
A facility failed to adequately monitor and maintain wander guard devices for residents, resulting in a resident with dementia exiting the building unsupervised. The staff lacked training on the system, and the devices' battery life and functionality were not checked, leading to a deficiency in preventing accidents.
A facility's QAPI program failed to update its WanderGuard policy and educate staff, leading to a resident elopement incident. The wander guard device did not function properly, and staff were unaware of system features and maintenance needs. Interviews revealed a lack of training and communication regarding the system's operation and policy updates.
A resident with dementia and impaired cognition was found without pants, despite having 17 pairs documented. Staff inconsistencies and lack of clear policies led to the loss of the resident's clothing, with confusion over laundry processes and inventory management.
A deficiency was identified in a facility's infection control program when staff failed to wear appropriate PPE, specifically gowns, during the care of a resident with a urinary catheter and a stage 4 pressure ulcer. Despite the presence of an Enhanced Barrier Precaution sign, staff were observed providing care without gowns, leading to direct contact with the resident's bedding. Interviews revealed a lack of awareness and understanding of PPE requirements, highlighting a gap in staff training and adherence to infection control policies.
Delayed Reporting of Alleged Abuse by Staff
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse was reported immediately, as required by both facility policy and state law. Two nurse aide trainees witnessed a certified nurse aide slap a resident across the face and verbally abuse the resident during care. Instead of reporting the incident immediately to a supervisor or nurse, the trainees discussed the event between themselves and delayed reporting it for two days. The incident was eventually reported to a certified nurse aide, who then escalated it to the unit manager, and subsequently to the administrator. The resident involved had diagnoses including diabetes, obesity, and a mood disorder, and was dependent on staff for toileting and required supervision for bed mobility. The resident was alert, oriented, and had no documented behaviors. At the time of the incident, the resident did not report any mistreatment or abuse to the social worker and denied being abused when interviewed, although the nurse aide trainees described the resident as being shocked or unfazed by the slap. There were no physical injuries observed or reported. Interviews with staff revealed that the nurse aide trainees were unsure of the reporting process and were fearful of losing their jobs, which contributed to the delay. The facility's policies clearly state that any suspicion of abuse must be reported immediately, not to exceed two hours after discovery, to the administrator and the state agency. The delay in reporting resulted in the administrator and the New York State Department of Health being notified outside of the required timeframe.
Inadequate Monitoring of Wander Guard Devices Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of wander guard devices for three residents, leading to a deficiency in preventing accidents. Specifically, the facility did not monitor the battery life and functionality of the wander guard signaling devices assigned to the residents. This oversight resulted in one resident exiting the building unsupervised without staff knowledge. The staff lacked education and training regarding the wander alert system and policy, contributing to the deficiency. Resident #14, who had diagnoses of dementia, depression, and borderline personality disorder, was identified as an elopement risk due to impaired safety awareness and wandering behavior. Despite having a wander guard device, the resident was able to exit the building unsupervised. The investigation revealed that the wander guard device was intact but failed to lock the doors or sound an alarm, indicating a malfunction. Staff interviews confirmed a lack of awareness and training on checking the battery life and functionality of the wander guard devices. Residents #12 and #29 were also identified as elopement risks with wander guard devices assigned to them. However, the facility did not implement checks on the individual wander guard tags until after the incident with Resident #14. The Director of Nursing acknowledged the failure to follow the wander guard policy regarding battery checks. The lack of proper monitoring and training on the wander guard system contributed to the deficiency in ensuring resident safety and preventing accidents.
Deficiency in WanderGuard System and Staff Training
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to perform necessary improvement activities related to tracking adverse resident events, analyzing their causes, and implementing preventative actions. Specifically, the facility did not ensure that their WanderGuard policy was updated, staff were educated about the wander guard system, and preventive actions were implemented to ensure resident safety. This deficiency was highlighted by an incident involving a resident who was found outside the building in their wheelchair, despite having a wander guard device that was supposed to prevent such occurrences. The investigation revealed that the wander guard device on the resident was intact but failed to lock the doors or set off an alarm, potentially due to a software update issue. Interviews with staff, including the Director of Nursing, Registered Nurse Supervisors, and Security Officers, indicated a lack of awareness and training regarding the functionality and maintenance of the wander guard system. Staff were not checking the individual wander guard tags or their batteries, and there was no audit log for the battery life of these devices. Further interviews with the facility's Administrator and the sales representative of the wander guard system confirmed that there had been no recent in-service training on the system, and the staff were unaware of the system's features, such as the tag health function. The Administrator admitted to not knowing about the malfunction or the need to update the policy to reflect changes. This lack of communication and training contributed to the failure in ensuring resident safety, as evidenced by the resident's elopement incident.
Failure to Safeguard Resident's Personal Clothing
Penalty
Summary
The facility failed to protect a resident's personal property from loss or theft, specifically regarding the resident's clothing. Resident #51, who had diagnoses including dementia and moderately impaired cognition, was found to have no pants available in their closet despite inventory sheets documenting 17 pairs of pants. The resident required extensive assistance with dressing and was non-ambulatory, making it crucial for the facility to manage their clothing needs effectively. During the survey, it was observed that the resident was often found without pants, and staff had to provide extra clothing that did not belong to the resident. Interviews with staff revealed confusion and inconsistency in the handling of the resident's clothing, with some staff suggesting that new staff might misplace items or that the laundry service had not returned them. The facility used different colored bags to separate personal clothing from facility linens, but this process was not consistently followed, leading to the loss of the resident's pants. The facility lacked specific policies on providing a homelike environment or safeguarding personal belongings, as confirmed by the Administrator. The Director of Nursing and other staff acknowledged the issue but did not have a clear solution or policy in place to prevent such occurrences. The Social Worker attempted to mitigate the situation by purchasing new pants for the resident, but the underlying issue of missing clothing remained unresolved.
Inadequate Use of PPE During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) during the care of a resident requiring enhanced barrier precautions. The deficiency was identified during an Extended Recertification survey, where it was observed that staff did not wear appropriate PPE, specifically gowns, while providing hands-on care to a resident with a urinary catheter and a stage 4 pressure ulcer. The facility's policy on Enhanced Barrier Precautions, as well as guidelines from the Centers for Medicare and Medicaid Services, require the use of gowns and gloves during high-contact activities for residents with chronic wounds or indwelling medical devices, regardless of their multidrug-resistant organism status. The resident involved had multiple sclerosis, a pressure ulcer in the sacral region, and neuromuscular dysfunction of the bladder, necessitating the use of a urinary catheter. Despite the presence of an Enhanced Barrier Precaution sign on the resident's door, staff members, including a Certified Nurse Aide and a Registered Nurse Unit Manager, were observed providing care without wearing gowns. The staff's clothing came into direct contact with the resident's bedding, increasing the risk of infection transmission. Interviews with the staff revealed a lack of awareness and understanding of the requirement to wear gowns during high-contact activities, even when not directly managing the catheter or wound. The Director of Nursing and the Infection Preventionist acknowledged the need for staff to wear gowns and gloves during high-contact activities to prevent the spread of multidrug-resistant organisms. However, the staff's failure to adhere to these precautions was attributed to a lack of proper education and understanding of the facility's infection control policies. The deficiency highlights a gap in staff training and awareness regarding the implementation of enhanced barrier precautions for residents with indwelling medical devices and chronic wounds.
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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 North Tonawanda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Schofield Residence | 2.7 mi | ★★★★★ | 0 | 0 |
| North Gate Health Care Facility | 3.1 mi | ★★★★★ | 1 | 0 |
| Safire Rehabilitation Of Northtowns, L L C | 3.5 mi | ★★★★★ | 2 | 0 |
| Mcauley Residence | 3.6 mi | ★★★★★ | 0 | 0 |
| Rosa Coplon Jewish Home And Infirmary | 3.8 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.