Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Gowanda Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with dysphagia, severe cognitive impairment, and a mechanical soft diet order was given regular-texture sausage from another resident’s tray instead of the prescribed consistency. Staff reported the resident was chewing, then made a gasp-like noise and appeared to choke; the resident became unresponsive, required abdominal thrusts and CPR, and a sheriff later removed a small food particle with suction. EMS and hospital records documented choking-related cardiac arrest and death.
Failure to Provide Prescribed Diet Led to Choking Event
Penalty
Summary
The facility failed to ensure that a resident with profound intellectual disabilities, dysphagia, severe cognitive impairment, and a prescribed mechanically altered diet received food consistent with that diet. The resident’s records showed a mechanical soft diet order, a history of holding food in the mouth or cheeks after meals, and speech-language pathology findings of rapid intake, large bite sizes, and oral residue between bites. The care plan called for upright positioning, observation for aspiration signs, and diet per SLP recommendations, and the Kardex indicated the resident required moderate assistance while eating with a small spoon to limit portion size. On the day of the event, staff gave the resident sausage from another resident’s tray after the resident had not eaten much. The sausage was described by the SLP and RD as regular texture, not mechanical soft, and staff stated they were not trained to cut regular food into a mechanically altered consistency. The CNA reported giving the resident small pieces of sausage, then later bringing another piece and cutting it while the resident was eating. The resident was observed chewing, then appearing to try to swallow and making a strange or gasp-like noise. Staff then recognized the resident as choking. The resident became rigid, coughed, lost respirations and pulse, and abdominal thrusts and CPR were initiated. A sheriff used a portable suction machine and removed a small piece of food described as a flat flake or particle measuring about one to two centimeters. EMS and hospital documentation stated the resident had choked on food, was briefly resuscitated, then went into cardiac arrest and expired later that evening. Interviews with staff and the medical director confirmed the food given was inconsistent with the resident’s prescribed diet and that the choking episode was associated with the resident’s collapse and death.
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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 Gowanda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fiddlers Green Manor Rehab And Nursing Center | 13.5 mi | ★★★★★ | 11 | 0 |
| Eden Rehabilitation Nursing Center | 14.1 mi | ★★★★★ | 3 | 0 |
| Jennie B Richmond Chaffee Nursing Home Company Inc | 14.2 mi | ★★★★★ | 0 | 0 |
| Autumn View Health Care Facility L L C | 19.8 mi | ★★★★★ | 3 | 0 |
| Elderwood At Hamburg | 20.2 mi | ★★★★★ | 3 | 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.