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 Garden Gate Health Care Facility during CMS and state inspections, most recent first.
The facility failed to provide meals at safe and appetizing temperatures, affecting multiple residents across various dining areas. Meals were often served late and cold, with missing condiments and issues with the coffee machine. Test tray observations confirmed that food items were not maintained at appropriate temperatures, impacting residents' dining experiences.
The facility failed to maintain sanitary food service conditions, with unlabeled food items, dirty equipment, and littered floors observed in the kitchen. Fruit flies were present due to poor cleanliness, affecting both the kitchen and resident areas. Additionally, the coffee maker was malfunctioning, causing inconvenience for residents. These issues indicate significant lapses in food service safety and equipment maintenance.
During a period of declared influenza prevalence, the facility failed to enforce its mask-wearing policy for unvaccinated staff, leading to multiple instances of non-compliance. Staff members, including CNAs and LPNs, were observed not wearing masks in resident care areas, despite having declined the influenza vaccine. Interviews revealed a lack of awareness and communication about the mask requirement, and the administration admitted to not maintaining an accurate list of vaccination statuses or providing formal education to staff.
Two residents in an LTC facility did not receive necessary grooming care. One resident with diabetes and dementia had significant facial hair, which staff failed to address despite the resident's discomfort. Another resident with dementia had long fingernails with debris, and staff did not provide nail care, impacting infection control and dignity. Staff interviews revealed a lack of adherence to facility policies on grooming and hygiene.
A resident with Parkinson's, depression, and severe malnutrition experienced continued weight loss due to inconsistent weekly weight monitoring, despite recommendations from the dietician. The care plan required weekly weights and nutritional supplements, but these were not consistently documented or followed. Staff interviews revealed a lack of adherence to the weight monitoring policy, with other care tasks prioritized over obtaining weights.
A resident with dysphagia and dementia was served regular consistency soup instead of the prescribed pureed consistency, despite their care plan and meal ticket indicating the need for pureed soup and supervision during meals. Staff were present but did not correct the error, posing a risk of choking or aspiration. Facility policies on accident prevention and eating assistance were not followed.
A facility failed to ensure that a pharmacist's recommendations for a resident's drug regimen were reported and acted upon by the attending physician and medical director. The recommendations, which included questioning the necessity of weekly lab tests and insulin administration frequency, were not communicated or addressed. Interviews revealed a breakdown in the process of handling pharmacy recommendations, leading to a deficiency in the drug regimen review process.
The facility failed to monitor antibiotic use for two residents, one with osteomyelitis and another with multiple sclerosis and urinary tract infections. Despite protocols, the antibiotics Cefadroxil and Macrobid were not tracked or reviewed by the Infection Preventionist or Antibiotic Stewardship Program. Staff interviews revealed a lack of awareness and documentation, indicating a system failure in monitoring antibiotic usage.
The facility failed to maintain a clean and safe environment, with issues such as non-functioning lights, debris on floors, and rusty commode chairs observed across multiple units. Staff interviews revealed lapses in cleaning protocols and maintenance reporting, while residents expressed dissatisfaction with the conditions. The administration acknowledged the deficiencies and the need for improved maintenance practices.
A resident with a history of frequent UTIs did not receive proper catheter care, as the urine collection bag was not kept below the bladder level during care, contrary to facility policy. Staff, including CNAs and an LPN, were unaware of the correct positioning, leading to urine backflow. The resident had a history of cerebral infarction and diabetes, with a care plan requiring catheter care every shift.
A resident on enhanced barrier precautions did not receive proper infection control care as staff failed to wear gowns during high-contact activities. The resident, with a history of stroke and diabetes, required significant assistance and was at risk for infections. Staff interviews revealed a lack of awareness and adherence to PPE protocols, with soiled linens improperly handled and no receptacle available in the resident's room.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for residents in multiple dining areas, including the B Unit dining room, D Unit dining room, C Unit hallway, A Unit hallway, and Main dining room. Observations and interviews revealed that meals were often served late, cold, and unappetizing, affecting numerous residents. Residents expressed dissatisfaction with the quality and temperature of the food, noting that meals were frequently served cold, and condiments were often missing. The Resident Council Meeting Notes documented ongoing concerns about late and cold meals, lack of condiments, and issues with the coffee machine. During interviews, residents reported that meals were served later than scheduled, sometimes as late as 7:40 PM, which disrupted their routines and the staff's ability to provide timely care. Residents also noted that the coffee maker had been broken for weeks, resulting in cold coffee and tea. Test tray observations confirmed that food items were not maintained at appropriate temperatures, with hot foods often below the recommended 140 degrees Fahrenheit, making them less palatable. The facility's policy required hot foods to be served hot and cold foods cold, but this was not consistently achieved. Staff interviews indicated a lack of awareness and adherence to proper food temperature guidelines. The Director of Nursing and Food Service Director acknowledged the issues with food temperatures and the broken coffee machine. Despite the facility's policy to ensure safe and sanitary food preparation and service, the deficiencies in food temperature and quality persisted, impacting residents' dining experiences and overall satisfaction.
Unsanitary Food Service Conditions and Equipment Malfunction
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of unsanitary conditions in the kitchen and dining areas. During a survey, it was noted that the kitchen contained unlabeled and undated food items in both the freezer and coolers. Equipment such as the floor stand mixer, soup kettle, and meat slicer were found with dried spills and food residues, indicating they had not been cleaned after use. Additionally, the kitchen and dishwashing room floors were littered with food debris and trash, and there were uncovered meal trays with uneaten food left on open carts and counters. The facility also experienced issues with fruit flies, which were observed in various areas, including the kitchen, dining room, and even in a resident's room. Pest control reports indicated a persistent problem with fruit flies due to poor cleanliness, with heavy activity noted in the kitchen and dishwashing areas. The presence of fruit flies was linked to the unsanitary conditions and improper handling of meal trays, as trays with leftover food were left unattended in hallways and dining areas. Furthermore, the facility's coffee maker was not functioning properly, requiring staff to manually heat water for brewing coffee. This issue led to delays and inconvenience for residents, as staff frequently had to reheat coffee upon request. The coffee maker had been broken for several days, and there was no alternative available for residents. These deficiencies highlight significant lapses in maintaining sanitary conditions and ensuring proper food service operations within the facility.
Failure to Enforce Mask-Wearing Policy During Influenza Prevalence
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a period when New York State had declared influenza prevalent. Specifically, staff members who had declined the influenza vaccine were observed not wearing face masks in resident care areas, contrary to the facility's policy and state regulations. The policy required unvaccinated staff to wear masks in all areas where residents are present to prevent the transmission of influenza, yet several staff members, including Certified Nurse Aides and Licensed Practical Nurses, were observed without masks while providing care. Interviews with staff revealed a lack of awareness and communication regarding the mask-wearing requirement. Certified Nurse Aides and Licensed Practical Nurses admitted to not wearing masks and were unaware of the necessity to do so due to the influenza prevalence declaration. The Director of Nursing and the Assistant Director of Nursing were responsible for ensuring compliance with the policy, but they failed to maintain an accurate and up-to-date list of staff vaccination statuses and did not effectively communicate the mask-wearing requirement to all staff. The facility's administration, including the Infection Control Preventionist and the Administrator, acknowledged the oversight in ensuring staff compliance with the mask-wearing policy. Despite receiving notifications about the influenza prevalence, there was no formal documentation or education provided to staff to reinforce the importance of wearing masks. This lack of communication and enforcement led to multiple instances of non-compliance, putting residents at risk of influenza transmission.
Deficiencies in Personal Hygiene and Grooming Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, two residents were observed to have deficiencies in personal care. One resident, who had diagnoses including type 2 diabetes mellitus, dementia, and essential tremor, was found with significant facial hair on multiple occasions. Despite the resident expressing discomfort with the facial hair, staff did not offer or provide shaving during care observations. Interviews with staff revealed that shaving should have been offered whenever facial hair was noticed, but it was not done, impacting the resident's dignity. Another resident, diagnosed with dementia, depression, and anxiety disorder, was observed with long fingernails and dark brown debris underneath. The resident required assistance with personal hygiene, but staff failed to provide nail care during morning care, despite the resident using their hands to feed themselves. Interviews with staff indicated that nail care should have been provided on shower days and as needed, but this was not done, raising concerns about infection control and the resident's dignity. The facility's policies on activities of daily living, morning and evening care, and nail care were not adhered to, as evidenced by the observations and staff interviews. The staff, including Certified Nurse Aides and Licensed Practical Nurses, acknowledged the importance of maintaining residents' grooming for dignity and infection control purposes but failed to implement these practices consistently. The Director of Nursing and the Administrator also emphasized the responsibility of staff to ensure residents' grooming needs were met, highlighting a gap between policy and practice.
Inconsistent Weight Monitoring Leads to Continued Weight Loss
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not consistently obtain weekly weights for a resident as recommended by the dietician, which was crucial for monitoring the resident's nutritional status. The resident, who had diagnoses including Parkinson's disease, depression, and severe protein-calorie malnutrition, experienced continued weight loss. The care plan required weekly weights and nutritional supplements, but these were not consistently documented or followed. The resident's weight was not consistently tracked, with several weeks missing documented weights. The dietician had incorporated weekly weights into the care plan, expecting the resident's weight to gradually increase. However, the last documented weight was on 2/12/25, and subsequent weights were not recorded until 3/18/25, showing a further weight loss. The dietician assumed no additional weight loss based on meal and snack consumption but was not certain due to the lack of consistent weight documentation. Interviews with staff revealed a lack of adherence to the weight monitoring policy. Certified Nursing Assistant #4, responsible for the resident's weekly weights, prioritized other care tasks over obtaining weights. The Registered Nurse Unit Coordinator and Director of Nursing acknowledged the inconsistency in weight documentation and the failure to follow the dietician's recommendations. The dietician stated that earlier notification of the weight loss trend could have led to interventions such as increased protein intake or appetite stimulants, which were not implemented due to the oversight.
Failure to Provide Correct Diet Consistency and Supervision
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that adequate supervision was provided to prevent accidents for one resident. Specifically, a resident with diagnoses including aphasia, dysphagia, and dementia was served regular consistency soup with intact broccoli pieces instead of the prescribed pureed consistency. This occurred despite the resident's care plan and meal ticket indicating the need for pureed soup and supervision during meals. The resident's diet order required nectar thick liquids and ground texture food, and the Swallow Discharge Summary highlighted the need for supervision and specific dietary modifications due to the resident's swallowing difficulties. During an evening meal observation, the resident was served the incorrect soup consistency, and although staff were present in the dining room, the error was not corrected. Interviews with facility staff, including the Food Service Director, Speech-Language Pathologist, and Director of Nursing, confirmed that the resident should have received pureed soup and that the failure to do so could have led to choking or aspiration. The facility's policies on accident prevention and eating assistance were not followed, resulting in a potential risk to the resident's safety.
Failure to Act on Pharmacist's Recommendations for Resident's Drug Regimen
Penalty
Summary
The facility failed to ensure that the pharmacist's recommendations for a resident's drug regimen were reported and acted upon by the attending physician and medical director. Specifically, the Consultant Pharmacist made recommendations on January 17, 2025, regarding the medication regimen of a resident with type 2 diabetes mellitus, dementia, and depression. These recommendations included questioning the necessity of weekly lab tests and the frequency of insulin administration. However, these recommendations were not communicated to the attending physician or medical director, nor were they acted upon. The facility's policy required that pharmacy recommendations be reviewed by the attending physician, who would document their agreement or disagreement and any actions taken. If no action was taken within 60 days, the Consultant Pharmacist was to notify the Director of Nursing. In this case, the recommendations were not addressed, and the Consultant Pharmacist followed up with an email on February 18, 2025, to the Unit Manager, but there was no documented response or action taken. Interviews with facility staff, including the Unit Manager, Consultant Pharmacist, Nurse Practitioner, Director of Nursing, and Medical Director, revealed a breakdown in the process of handling pharmacy recommendations. The Unit Manager and medical providers did not recall receiving or addressing the recommendations, and the Director of Nursing and Medical Director expressed expectations that recommendations should be addressed promptly. The failure to act on the pharmacist's recommendations resulted in a deficiency in the facility's drug regimen review process.
Failure to Monitor Antibiotic Use in Residents
Penalty
Summary
The facility failed to ensure that its infection control program included antibiotic use protocols and a system to monitor antibiotic use for two residents. Resident #16, who had diagnoses including osteomyelitis, diabetes mellitus, and peripheral vascular disease, was receiving Cefadroxil for suppressive therapy since October 2024. Despite the comprehensive care plan indicating the need for monitoring, there was no evidence that the antibiotic use was tracked by the Infection Preventionist or the Antibiotic Stewardship Program. Resident #52, with diagnoses including multiple sclerosis, acute promyelocytic leukemia in remission, and urinary tract infections, was on Nitrofurantoin Monchyd Macro (Macrobid) for prophylaxis since October 2021. The facility's records did not show any monitoring or tracking of this antibiotic use, and it was not included in the lists provided by the facility's mechanisms for monitoring antibiotic use. Interviews with facility staff, including the Pharmacy Client Successor, Consultant Pharmacist, Assistant Director of Nursing, Director of Nursing, and the Administrator, revealed a lack of awareness and documentation regarding the antibiotic use for these residents. The staff acknowledged that the antibiotics should have been monitored and discussed in the Antibiotic Stewardship/Quality Assurance meetings, but this did not occur, indicating a failure in the facility's system to track and review antibiotic usage effectively.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents across multiple units, as observed during a complaint investigation. Specifically, issues were noted with walls in disrepair, floors with black debris, non-functioning over-the-bed lights, and soiled and rusty commode chairs. These deficiencies were observed in the A, C, and D Units, with specific rooms having missing paint, spackled but unsanded and unpainted walls, and debris on floors and furniture. The facility's policies on floor care and maintenance were not adhered to, as evidenced by the presence of dirt and debris in resident rooms and common areas. Interviews with staff revealed a lack of adherence to cleaning protocols and maintenance reporting. Housekeeping staff were responsible for daily cleaning tasks, including mopping and disinfecting, but failed to maintain cleanliness in several areas. Additionally, maintenance issues such as non-functioning lights and rusted commode chairs were not addressed promptly, despite the facility's policy of using an electronic work order system to facilitate repairs. Staff interviews indicated that maintenance issues were often verbally reported but not consistently followed up on, leading to prolonged deficiencies. Residents expressed dissatisfaction with the conditions, particularly regarding non-functioning lights and the presence of debris. One resident reported that their over-the-bed light had not worked for a month, impacting their comfort. The facility's administration acknowledged the expectations for daily cleaning and maintenance reporting but noted ongoing issues with floor maintenance and the need for replacements. The Director of Nursing highlighted the risk of cross-contamination from dirty linens left on the floor, emphasizing the importance of proper disposal practices.
Improper Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to ensure proper catheter care for a resident with a history of frequent urinary tract infections. During a complaint investigation, it was observed that the urine collection bag was not kept below the level of the resident's bladder during care, which is contrary to the facility's policy. The catheter care policy, dated 1/01/2000, requires that the drainage bag be kept below the bladder to prevent urine backflow and potential infections. However, during an observation, the urine collection bag was placed at the level of the resident's bladder, leading to backflow of urine during care. The resident involved had a history of cerebral infarction and diabetes, with mild cognitive impairment, and was usually understood and able to understand. The resident's care plan indicated the need for catheter care every shift due to obstructive uropathy and frequent urinary tract infections. Despite these instructions, staff members, including two Certified Nursing Aides and a Licensed Practical Nurse, failed to maintain the correct position of the urine collection bag during care. Interviews with the staff revealed a lack of awareness regarding the proper positioning of the urine collection bag, which was confirmed by the facility's Assistant Director of Nursing and Director of Nursing.
Plan Of Correction
Plan of Correction: Approved February 2, 2025 The facility will continue to ensure that each resident receives adequate treatment and services for a foley catheter, specifically proper placement of urine collection bag below waist-level to prevent complication. Corrective action took place immediately following care to Resident #4, placing urinary collection bag below level of bladder. Resident was assessed and monitored for 5 consecutive days for adverse effects. None noted. The residents’ care plan was reviewed and in concert with the current needs and a medical records review was completed with no abnormal findings. The Certified Nursing Assistants (#1 and #2) and Licensed Practical Nurse (#1) was immediately counseled and re-educated regarding proper placement of urinary collection bags during and after care, patency of tubing, and drainage bag below level of bladder to maintain unobstructed urine flow and prevent backflow of urine into the bladder. Staff has been audited by the Clinical Instructor and successfully demonstrated understanding of procedures. No further concerns have been identified. The facility identified other areas that could potentially be affected by the deficient practice by: - All residents with foley catheters had the potential to be affected by the deficient practice. - The Clinical Instructor conducted resident audits on all those with catheters verifying proper placement. There were no further issues. Measures that will be put in place or systematic changes to ensure that the deficient practice will not recur: - The Clinical Instructor provided an educational program to all certified nursing assistants and licensed nursing staff on proper placement of urinary collection bags during and after care, patency of tubing, and drainage bag below level of bladder to maintain unobstructed urine flow and prevent backflow of urine into the bladder. - The Clinical Instructor/Designee will conduct weekly audits of 50% of the resident population who have Foley catheters to verify proper placement of drainage bags. Audits will continue until 100% compliance is attained for 8 consecutive weeks. Results of the above will be provided to the Quality Improvement Committee on an ongoing basis to monitor compliance. The Director of Nursing will be responsible for monitoring compliance and follow up as necessary. If 100% compliance is not found, the staff involved will be counseled. The Quality Improvement Committee may make further recommendations including, but not limited to, ongoing education, additional audits, and/or process changes. Corrective action will be completed by (MONTH) 6, 2025. The Director of Nursing is responsible for the implementation of this plan with the Facility Administrator having overall responsibility for the conduct of the plan.
Inadequate Infection Control Practices for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases and infections for a resident on enhanced barrier precautions. The resident, who had a history of cerebral infarction and diabetes, required significant assistance for personal hygiene and was at risk for infections due to pressure ulcers and urinary tract infections. Despite these precautions, staff did not adhere to the required use of personal protective equipment (PPE) such as gowns during high-contact care activities. During an observation, two Certified Nurse Aides (CNAs) were seen providing care to the resident without wearing gowns, despite the presence of a sign indicating the need for enhanced barrier precautions. The CNAs engaged in activities such as emptying a urine drainage bag and providing incontinence care without the appropriate PPE. Additionally, soiled linens were improperly handled, being placed directly on the floor instead of in a designated receptacle, which was not available in or near the resident's room. Interviews with the staff revealed a lack of awareness and adherence to the enhanced barrier precautions. One CNA admitted to forgetting to wear a gown, while another was unsure of the necessity of wearing one. A Licensed Practical Nurse (LPN) also failed to wear a gown during treatment, allowing their uniform to come into contact with the resident's bed linens. The Unit Manager and the facility's Infection Preventionist confirmed the requirement for PPE use during hands-on care for residents on enhanced barrier precautions, highlighting a gap in compliance and awareness among the staff.
Plan Of Correction
Plan of Correction: Approved February 2, 2025 The facility will continue to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by: Resident # 4 immediately received perineal care and clothing change. The resident was monitored for 5 consecutive days for any adverse effects. None noted. The resident’s care plan was reviewed and is in concert with the resident’s current needs and a medical record review completed with no abnormal findings. Environmental surfaces within the room were immediately disinfected and receptacles for soiled linen was placed inside the room and stocked cart of PPE supplies placed outside of the room. The Certified Nursing Assistants (#1 and #2) and Licensed Practical Nurse (#1) who provided care and handled linen was immediately counseled and re-educated regarding infection control practices including Enhanced Barrier Precautions (EBP) protocols, donning and doffing PPE, incontinent care, foley care, skin barrier application, linen handling, and handwashing procedures. Staff also received education on facility protocols for precaution signage to identify resident needs. Staff has been audited by the Clinical Instructor and successfully demonstrated understanding of procedures. No further concerns have been identified. The facility identified other areas that could potentially be affected by the deficient practice by: - All residents had the potential to be affected by the deficient practice. - The Clinical Instructor conducted 5 resident audits per unit verifying proper infection prevention and control practices. Audits also verified appropriate EBP setup was in place and accessible to staff. Any further issues were immediately rectified and staff counseled. Measures that will be put in place or systematic changes to ensure that the deficient practice will not recur: - The Clinical Instructor provided an educational program to all certified nursing assistants and licensed nurses regarding infection prevention and control and specifically related to EBP. Such education also included donning and doffing PPE, incontinent care, foley care, skin barrier application, linen handling, and handwashing procedures. - The Clinical Instructor/Designee will conduct weekly audits of (2) residents per unit to verify appropriate infection prevention and control standards. Audits will continue until 100% compliance is attained for 8 consecutive weeks. - The Environmental Services Manager will ensure rooms identified requiring EBP have the proper receptacles for donning and doffing PPE. Auditing of each EBP room setup will be conducted weekly. Audits will continue until 100% compliance is attained for 4 consecutive weeks. Results of the above will be provided to the Quality Improvement Committee on an ongoing basis to monitor compliance. The Director of Nursing will be responsible for monitoring compliance and follow up as necessary. If 100% compliance is not found, the staff involved will be counseled. The Quality Improvement Committee may make further recommendations including, but not limited to, ongoing education, additional audits, and/or process changes. Corrective action will be completed by (MONTH) 6, 2025. The Director of Nursing is responsible for the implementation of this plan with the Facility Administrator having overall responsibility for the conduct of the plan.
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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 Cheektowaga
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elderwood At Cheektowaga | 1.1 mi | ★★★★★ | 4 | 0 |
| Seneca Health Care Center | 2.9 mi | ★★★★★ | 1 | 0 |
| Elderwood At Lancaster | 3.7 mi | ★★★★★ | 2 | 0 |
| Safire Rehabilitation Of Southtown, L L C | 4.2 mi | ★★★★★ | 16 | 0 |
| Mercy Hospital Skilled Nursing Facility | 4.8 mi | ★★★★★ | 0 | 0 |
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