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 Delaware Oaks Center For Rehabilitation And Nursin during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was inappropriately touched by another cognitively impaired resident in a common area, despite both being identified as at risk for victimization and interventions being in place. The incident was witnessed by another resident and a CNA, and the facility's investigation determined that non-consensual sexual contact had occurred.
Two residents were involved in an incident of alleged inappropriate contact, which was witnessed and immediately reported to the Administrator. Although the Administrator initiated an internal response, the DON did not report the allegation to the State Agency within the required two-hour timeframe, citing the need to complete the investigation first. This delay violated regulations requiring immediate reporting of suspected abuse.
Staff failed to follow enhanced barrier precautions for a resident with multiple pressure ulcers and osteomyelitis, as required by facility policy. During high-contact care activities, including wound care and changing linens, staff wore gloves but did not use gowns, resulting in their uniforms contacting the resident's bed linens. Interviews revealed staff were unaware or did not notice the need for gowns, despite posted signage and policy directives.
The facility failed to maintain an effective pest control program, leading to the presence of flies and spiders in resident units and the kitchen. Observations revealed numerous live and dead insects, and interviews with staff and residents highlighted ongoing issues with flies. The facility lacked documentation for recent exterminator treatments, and residents expressed discomfort due to the pests.
The facility failed to maintain a safe and sanitary environment, with a leaking roof causing water damage and unpleasant odors in resident areas. Maintenance staff were aware of the issues but awaited corporate approval for repairs. Observations revealed disrepair in shower stalls, soiled privacy curtains, and cracked windows, while residents reported dissatisfaction with the conditions.
A resident with dementia repeatedly wandered into another resident's room, leading to altercations and minor injuries. Despite care plan interventions like stop signs, these measures were ineffective, and staff inconsistently recognized the incidents as abuse. The facility failed to protect the resident's right to be free from abuse.
A resident with cerebral palsy and severe cognitive impairment was not released from a wheelchair seatbelt restraint every two hours as required by the facility's policy. Staff interviews revealed confusion about the restraint policy, with some aides not releasing the seatbelt due to the resident's behavior. The RN Unit Manager and DON confirmed the seatbelt should be released every two hours, highlighting a deficiency in following the care plan.
The facility failed to implement person-centered care plans for two residents, resulting in deficiencies. A resident with schizoaffective disorder did not have a stop sign across their doorway as required, and staff were unaware of this intervention. Another resident with schizophrenia had stop signs that were frequently removed and not consistently checked. Observations and staff interviews highlighted a lack of communication and monitoring regarding these interventions.
A resident with pressure ulcers did not receive an air mattress as recommended by the Physician Wound Consultant, despite multiple recommendations. The resident, who had several medical conditions and Stage 3 pressure ulcers, was observed without the air mattress on several occasions. Staff members were unaware of the recommendation, and there was no documentation that the recommendation was implemented.
A resident with limited mobility and a history of contractures did not receive appropriate treatment to prevent further decline in range of motion. Despite recommendations for a rolled washcloth to be used in the resident's left hand, it was not consistently applied due to a clerical error and lack of communication among staff. This oversight led to the resident not receiving necessary interventions to maintain joint mobility and prevent skin breakdown.
A resident with specific dietary preferences for a vegetarian diet was repeatedly served meals containing meat, despite clear documentation and communication of their preferences. Facility staff, including the dietician and dietary director, acknowledged the oversight and the expectation for meal tickets to be checked for accuracy was not met.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident, both of whom were severely cognitively impaired and lacked the ability to consent. The incident involved one resident in a wheelchair placing their hand under another resident's shirt and rubbing their breast, as witnessed by another resident and a certified nurse aide. Both residents involved had significant cognitive impairments, with one diagnosed with dementia, depression, and diabetes, and the other with aphasia, Alzheimer's disease, and PTSD. Care plans for both residents identified them as being at risk of victimization due to their cognitive limitations and inability to understand their surroundings. Despite documented interventions to provide support and ensure a safe environment, the incident occurred in a common area after an activity, where one resident repeatedly approached the other. Staff had to intervene multiple times, but the inappropriate contact still took place and was reported by witnesses. The facility's policy defined sexual abuse as non-consensual sexual contact of any type with a resident, and the investigation found reasonable cause to believe that abuse had occurred.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, to the administrator and to the State Survey Agency. Specifically, an incident was observed in which one resident was seen touching another resident inappropriately. This was immediately reported to the Administrator by a witness. The Administrator then contacted the nurse supervisor and instructed them to intervene and begin an investigation. However, the incident was not reported to the State Agency within the required timeframe. Interviews with facility staff revealed that the Administrator believed the Director of Nursing (DON) would complete the required reporting, while the DON stated they did not report the allegation on time because they had not completed their investigation and had not determined if the incident had occurred. The facility's policy and state regulations require immediate reporting of suspected or actual abuse, regardless of whether the investigation is complete. The delay in reporting resulted in noncompliance with regulatory requirements for timely notification of abuse allegations.
Failure to Adhere to Enhanced Barrier Precautions During Resident Care
Penalty
Summary
During a complaint investigation, it was observed that staff failed to follow the facility's enhanced barrier precautions policy for infection prevention and control. Specifically, a resident with multiple pressure ulcers, including a stage IV wound and a diagnosis of osteomyelitis, was on enhanced barrier precautions requiring the use of gowns and gloves during high-contact care activities. Despite clear signage and policy directives, staff members providing direct care—including dressing, changing briefs, changing linens, and performing wound care—were observed wearing gloves but not gowns, resulting in their uniforms coming into contact with the resident's bed linens. The resident in question had significant medical needs, including hemiplegia, hemiparesis following a stroke, and chronic wounds, which placed them at increased risk for infection. The care plan indicated the need for enhanced barrier precautions due to these wounds and the associated risk of infection. However, during multiple care activities, staff did not adhere to the required use of personal protective equipment, as outlined in the facility's policy and posted instructions. Interviews with staff revealed a lack of awareness and understanding regarding the resident's precaution status and the proper use of personal protective equipment. One certified nurse aide was unaware the resident was on enhanced barrier precautions, while another did not notice the PPE setup or signage. The LPN involved in wound care stated that a gown was not used because the wounds did not have secretions, despite policy requirements. The infection control preventionist and director of nursing confirmed that enhanced barrier precautions were in place and that staff were expected to use gowns and gloves during all high-contact care activities for residents with wounds.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of insects such as house flies, spiders, and fruit flies in two resident units and the main kitchen. The facility's policy, dated January 2024, stated that it would maintain an ongoing pest control program to ensure the facility is free of insects. However, the facility was unable to provide exterminator service inspection reports for July and August 2024, and the June 2024 report indicated worsening drain fly issues that required treatment. Observations made during the survey revealed numerous instances of live and dead flies in various areas, including the second-floor shower room, dining room, nurses' station, and multiple resident rooms. In the kitchen, a significant number of dead flies were found on sticky paper in a plug-in insect trap, and live flies were observed in the dish and food storage rooms. Additionally, spiders were noted in some resident rooms, with one resident expressing discomfort about spiders above their bed. Interviews with staff and residents highlighted ongoing issues with flies, with reports of flies being present for weeks or months. The Director of Maintenance acknowledged an increase in fly activity and stated that the facility had increased exterminator visits to address the issue. However, documentation for these treatments was not available. Residents expressed annoyance and discomfort due to the presence of flies, with some taking measures such as using glue traps to manage the problem themselves.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by multiple deficiencies observed during a complaint investigation. The roof of the facility was in disrepair, leading to active leaks that resulted in stained and wet ceiling tiles. Maintenance staff had previously patched the roof with silicone, but the patch was no longer effective, and the roof continued to leak during rain. This ongoing issue led to water damage in several resident rooms and common areas, with ceiling tiles becoming saturated and falling apart. Additionally, the facility had not addressed the need for a new roof, despite having received multiple repair estimates. The interior of the facility was also found to be in poor condition, with walls and floors in disrepair, and strong urine odors present in several areas, including resident rooms and the nurses' station. Observations revealed missing caulk and sealant in shower stalls, black spots and debris along the walls, and rust stains in the shower room. Privacy curtains were soiled, and a cracked window was noted in one of the resident rooms. Residents and their representatives reported dissatisfaction with the conditions, citing unpleasant odors and leaking ceilings. Interviews with facility staff, including the Director of Maintenance and housekeeping personnel, confirmed awareness of the issues but indicated delays in addressing them. The Director of Maintenance acknowledged the need for a new roof and stated that they were waiting for corporate approval to proceed with repairs. Housekeeping staff were responsible for cleaning resident rooms, but the presence of odors and soiled areas suggested that cleaning schedules and audits were not effectively implemented. The facility's failure to maintain a sanitary and orderly environment compromised the residents' right to a homelike setting.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by a resident-to-resident altercation involving Resident #72 and Resident #61. Resident #72, who had severe cognitive impairment and wandering behaviors, entered Resident #61's room on two occasions, resulting in physical altercations. The care plan for Resident #72 included interventions such as placing stop signs at the doorway to prevent wandering into other residents' rooms, but these were not consistently in place or effective. Resident #72, diagnosed with dementia, hypothyroidism, and vitamin D deficiency, was at risk of being taken advantage of due to cognitive impairment. Despite interventions like stop signs, Resident #72 continued to wander into Resident #61's room, leading to altercations where Resident #61, who was cognitively intact but had verbal behaviors directed toward others, hit Resident #72 with objects like a bed remote and a television remote. These incidents resulted in minor injuries to Resident #72, including hematomas on the head. Staff interviews revealed that the stop signs were not consistently maintained, and Resident #72 was known to remove them. The facility's staff, including CNAs and the Director of Social Work, acknowledged the incidents as physical abuse, but there was inconsistency in recognizing and addressing the abuse. The Director of Nursing did not initially consider the incidents as abuse due to the residents' cognitive and psychiatric conditions, while the Administrator later acknowledged the incidents as abusive, indicating a lack of consistent understanding and implementation of abuse prevention protocols.
Failure to Release Physical Restraint as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints unless needed for medical treatment, as observed during a standard survey. The resident, who had diagnoses including cerebral palsy, seizures, and anxiety disorder, was using a wheelchair seatbelt restraint that was not released every two hours as ordered. The facility's policy required that restraints be released every two hours to allow for motion and exercise, but during an observation period, the seatbelt was not released for nearly three hours. Interviews with staff revealed inconsistencies in understanding and implementing the restraint policy. A Certified Nurse Aide was unsure why restraints needed to be released every two hours, and another aide did not release the seatbelt during breakfast due to the resident's behavior. The Registered Nurse Unit Manager and the Director of Nursing both stated that the seatbelt was supposed to be released every two hours, but there was a discrepancy in whether the seatbelt was considered a restraint. This lack of adherence to the care plan and policy led to the deficiency noted in the survey.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to implement a person-centered care plan for two residents, leading to deficiencies in meeting their medical and nursing needs. Resident #63, diagnosed with schizoaffective disorder and bipolar disorder, was supposed to have a stop sign across their doorway to prevent other residents from entering their room due to safety concerns related to impulsive behaviors and involvement in resident-to-resident altercations. Despite being documented in the care plan and Kardex, observations over several days revealed that the stop sign was not in place, and staff interviews indicated a lack of awareness and communication regarding this intervention. Similarly, Resident #61, with diagnoses including schizophrenia and major depressive disorder, was to have two stop signs across their doorway as per their care plan. However, observations showed that the stop signs were either absent or improperly placed, and staff interviews revealed that the signs were frequently removed by residents or not consistently checked. The lack of a schedule for checking the stop signs and the ease with which they could be removed contributed to the failure in implementing the care plan as intended.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, the recommendations made by the Physician Wound Consultant for an air mattress were not implemented for Resident #49, who had diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, and peripheral vascular disease. The resident was cognitively intact and had three Stage 3 pressure ulcers. Despite multiple recommendations from the Physician Wound Consultant for an air mattress to aid in the healing of a pressure ulcer on the left posterior thigh, the facility did not follow through with this recommendation. Observations and interviews revealed that the air mattress was not present on the resident's bed during multiple checks, and staff members, including a Certified Nurse Aide, a Registered Nurse Unit Manager, and a Licensed Practical Nurse, were unaware of the recommendation for an air mattress. The Director of Nursing stated that recommendations were placed in the provider's mailbox for review and order, but there was no documentation that the recommendation was carried out. The Physician Wound Consultant confirmed the recommendation for an air mattress and was unaware that it had not been implemented.
Failure to Provide Contracture Management for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for a resident with limited mobility. Resident #5, who had a contracture and was diagnosed with hemiplegia and hemiparesis following a stroke, was not provided with a device to prevent further contracture. The facility's policy on contracture management required interventions to improve, maintain, and prevent deterioration of joint mobility, but these were not adequately implemented for Resident #5. Observations and interviews revealed that Resident #5 was supposed to have a rolled washcloth in their left hand to prevent contractures and maintain hygiene, but this intervention was not consistently applied. The task for the rolled washcloth was canceled in November 2022, and subsequent therapy evaluations recommended its use, but it was not re-added to the care plan or task list for Certified Nurse Aides. Staff interviews indicated a lack of awareness and communication regarding the necessity of the rolled washcloth, leading to its absence during multiple observations. The Occupational Therapist acknowledged a clerical error in failing to update the care plan and task list after a June evaluation, which contributed to the oversight. The Director of Therapy confirmed that the rolled washcloth was a necessary intervention for Resident #5 to prevent worsening contractures and skin breakdown. The deficiency was identified as a failure to ensure that Resident #5 received the appropriate treatment and services to maintain their range of motion, as required by the facility's policy and regulatory standards.
Failure to Accommodate Resident's Vegetarian Dietary Preference
Penalty
Summary
The facility failed to ensure that a resident received meals that accommodated their documented dietary preferences, specifically a vegetarian diet. The resident, who had diagnoses including protein-calorie malnutrition, dysphagia, and chronic diastolic heart failure, had clearly communicated their preference for vegetarian meals to the registered dietician, and this preference was documented in the resident's care plan and meal tickets. Despite this, the resident was served a breakfast meal containing sausage, which they did not eat due to their vegetarian preference. The resident reported that receiving meat products on their meal trays was a recurring issue. Interviews with facility staff, including the registered dietician, dietary director, and nursing staff, revealed that the expectation was for dietary staff to follow the meal tickets and for supervisors to check trays before they were sent to the units. However, this process failed, resulting in the resident receiving a meal that did not meet their dietary preferences. The dietary director acknowledged that the meal tray with sausage should not have been served, and the director of nursing and other staff members confirmed that meal tickets should be checked for accuracy before being served to residents.
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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) |
|---|---|---|---|---|
| Buffalo Center For Rehabilitation And Nursing | 0.4 mi | ★★★★★ | 5 | 0 |
| Humboldt House Rehabilitation And Nursing Center | 1.1 mi | ★★★★★ | 28 | 1 |
| Highpointe On Michigan Health Care Facility | 1.2 mi | ★★★★★ | 2 | 0 |
| St Catherine Laboure Health Care Center | 1.4 mi | ★★★★★ | 5 | 0 |
| Ellicott Center For Rehabilitation And Nursing | 1.9 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.