Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Safire Rehabilitation Of Southtown, L L C during CMS and state inspections, most recent first.
A resident with dementia and type 2 DM, assessed and care planned to require two staff for transfers, was transferred using a mechanical lift by only one CNA, in violation of facility policy requiring two caregivers for such transfers. The CNA, who had been trained on mechanical lift use, reported proceeding alone because they believed no one was available to help and the resident was asking to go to bed near the end of the CNA’s shift. The resident was later found on the floor near the lift with a significant leg laceration, and subsequent review confirmed the lift and sling were functioning properly while other staff reported that two aides had been working on each hallway during that shift.
The facility did not maintain enough RN, LPN, and CNA coverage to meet resident needs, with multiple staff call-offs and unit shortages leaving some units without CNAs and requiring supervisors and an ADON to help. Residents reported long waits for call lights, delayed toileting and incontinence care, missed showers, and being kept in bed later than preferred because staff were too short to complete care on time.
Food and beverages were served at improper temperatures and were described as unappetizing across multiple meal observations. Residents reported cold, bland, dry, mushy, or burnt meals, and test trays on several units showed hot foods below expected serving temperatures while milk and drinks were not cold enough. The FSD acknowledged the hot foods were too cool and the DON was unaware of the complaints.
Surveyors found multiple food safety failures in the kitchen and a nourishment room, including undated, unlabeled, and expired foods in coolers and refrigerators, opened items without dates, and improperly stored resident and employee foods. A staff member preparing lunch trays was not wearing a beard guard, and the kitchen also had a dust-laden AC unit and a plumbing leak near the dishwasher area. The FSD and DON stated food in unit refrigerators needed resident names and dates and should be used within 3 days.
A facility failed to keep resident rooms, bathrooms, and shower areas sanitary and in good repair. Observations found stained privacy curtains, a loose toilet seat, dirty shower areas, a bowed and damp ceiling tile, dust-covered oxygen concentrator filters, unlabeled personal care items, no paper towels, malodorous bathrooms, and a ripped, stained air mattress. Staff gave inconsistent accounts of who was responsible for cleaning and maintaining these areas, and the DON stated there was no scheduled cleaning for oxygen concentrators and filters.
Infection control failures were observed during wound care, transfers, and medication passes. A resident with wounds, a catheter, and a colostomy had a soiled brief placed on the floor without a barrier, and staff caring for another resident on EBP did not wear required gowns during showering, transferring, and wound care. An LPN handled oral meds with bare hands, reused meds that touched the med cart, and personal beverages were found on the med cart. The facility also lacked conspicuous COVID-19 vaccination/booster signage.
A resident with a cognitively intact status and diagnoses including a femur fracture, AFib, and anxiety had diphenhydramine at the bedside and stated they took it on their own for sleep. There was no documented interdisciplinary assessment, no order for self-administration or bedside storage, and staff interviews confirmed the resident was not authorized to self-administer meds. An opened bottle of diphenhydramine was observed on the tray table and later in the nightstand.
A resident who was cognitively intact and dependent on staff for bathing did not receive the shower preference documented in the care profile, with aides instead providing bed baths or recording refusals without supporting documentation. Another cognitively intact resident with a documented preference to rise by 7:00 AM was kept in bed past the preferred time, despite the resident stating a desire to be up before breakfast and staff acknowledging the preference was known but not followed because of staffing.
Failure to provide required nail care for two residents was identified during survey. One resident with stroke-related hemiplegia and aphasia had long fingernails on the right hand despite needing staff help with ADLs, and the resident said the nails bothered them and wanted them trimmed. Another resident with DM had fingernails extending beyond the finger pads with thick brown debris underneath; the resident was dependent for bathing and personal hygiene, had a physician order for weekly nail trimming by an LPN, and the record showed missed nail care with no documented refusal.
A resident with a fall-related shoulder injury reported severe pain and requested an x-ray, but the RN supervisor did not notify the provider and told the resident x-rays were not being done because it was a holiday; pain meds and x-ray orders were delayed, and the fracture was later confirmed. Another resident with severe cognitive impairment had a visible forearm skin tear reported by a CNA, but there was no documented assessment, treatment, or incident report until later.
A resident with a Stage 3 coccyx pressure ulcer and diabetes did not receive the wound consultant’s recommended air mattress. Staff notes and observations showed the resident remained on a standard mattress with no documented refusal, while the care plan and care profile were not updated to reflect the pressure-relieving device. During this period, the resident’s coccyx wound declined and a new Stage 3 pressure ulcer developed on the posterior thigh.
A resident with hypothyroidism did not receive their prescribed Synthroid medication on multiple occasions due to unavailability and lack of proper documentation and notification by the nursing staff. The medication was not located in the facility's dispensing system, and the physician was not informed of the missed doses until later. This resulted in a deficiency in the facility's adherence to professional standards of practice.
A facility was found deficient in meeting residents' nutritional needs, with insufficient protein portions and lack of standardized recipes. Dietary staff prepared meals based on personal knowledge, and the facility's menus were not reviewed by a dietitian. The facility also lacked written nutrient guidelines and did not provide individualized menus to residents.
A facility failed to provide meals that accommodated the dietary needs and preferences of three residents, including a resident with celiac disease who was not given gluten-free options. Despite documented dietary requirements, residents received meals that did not align with their preferences or medical needs. Staff interviews revealed a lack of communication and understanding of dietary requirements, with budget constraints cited as a reason for not ordering necessary gluten-free products.
A resident with severe morbid obesity and other conditions was given bed baths instead of showers as per their preference and care plan. Staff cited safety concerns with the shower chair, but a suitable bariatric chair was available on another floor. The care plan was not updated, and the resident's preference was not honored.
The facility failed to comply with Section 915 of the 2020 Fire Code of New York State by not conducting required testing and maintenance of carbon monoxide detectors. Observations and interviews revealed that some detectors did not respond to testing, and there was no task in the maintenance system to address their testing.
Single-Staff Mechanical Lift Transfer Leads to Resident Fall and Laceration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision during a mechanical lift transfer, resulting in a resident fall and injury. Facility policy for "Resident Transfer Using a Total Mechanical Lift" required that two or more caregivers be present and assisting at all times, with at least two caregivers having hands-on contact with the resident and the lift. The resident involved had dementia and type 2 diabetes mellitus, was cognitively impaired, and was assessed on the Minimum Data Set as needing assistance of two staff members for transfers. The resident’s care plan also documented dependence on two staff for transfers using a gait belt. On the date of the incident, the resident was transferred via mechanical lift by a single CNA, contrary to policy and the resident’s assessed needs. The CNA reported they could not find another staff member to assist, knew they should not perform the transfer alone, but proceeded because the resident repeatedly requested to go to bed and it was the end of the CNA’s shift. The resident was later found on their left side near the mechanical lift with a six-inch laceration on the left leg and was sent to the emergency room. Subsequent examination of the sling and lift by nursing leadership found the equipment to be in good working order. Staff interviews confirmed that two staff members were expected for mechanical lift transfers and that other aides had been available on the unit at the time of the incident.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility did not provide sufficient nursing staff on a 24-hour basis to meet residents’ needs, and the report states that this resulted in delays and missed care for multiple residents. The facility’s staffing plan called for specific RN, LPN, and CNA coverage across all shifts, but the 10/31/2025 staffing sheet showed shortages on the evening shift, including no CNAs on the Yellow unit, one CNA leaving early on the Blue unit, and one CNA leaving early on the Green unit. The report also notes that multiple supervisors and an assistant director of nursing were called in to assist, and residents later complained that there was no staff on the evening shift. Resident and staff interviews described delayed assistance, incomplete care, and residents remaining in bed later than preferred because staff were not available. One resident stated staff did not usually get them up until 11:00 AM or later even though they wanted to be up by 7:45 AM, and staff acknowledged that low staffing sometimes prevented honoring that preference. Another resident stated they had not had a shower in three weeks and staff explained that there was not enough staff on the evening shift to provide an actual shower for a two-assist resident, so a bed bath was given instead. Staff also reported that on the evening shift there were multiple call-offs, no aides on one unit, and residents on the Yellow unit had not been rounded on when staff were floated there to help put residents to bed. Additional interviews from residents and family members described long waits for call lights, delayed toileting and incontinence care, missed showers, and difficulty getting help across shifts and on weekends. One resident reported waiting hours for call lights to be answered and long delays in receiving incontinence care; another reported waiting 30 minutes for a call light to be answered after being soiled; another stated showers were not completed and residents were left in saturated briefs for extended periods. Staff interviews confirmed that units were often staffed with too few CNAs and that nurses were frequently required to help with aide duties, while some residents were left without timely care because staff could not get to everyone in a timely manner.
Food Served at Improper Temperatures and Poor Quality
Penalty
Summary
Food and drink were not served at palatable, attractive, and safe temperatures for residents on the Green, Yellow, and Blue Units during meal service. During the survey, residents on the Resident Council stated that food was served cold for all meals, was bland, portions were too small, and pasta was served too often. Individual residents also reported that meals were frequently lukewarm, cold, dry, mushy, burnt, or lacking taste, and one resident stated breakfast pancakes tasted like rubber. During lunch observations on the Green, Yellow, and Blue Units, dietary carts arrived and trays were passed to residents before temperatures were checked. Test trays showed hot foods below expected serving temperatures and cold items above expected cold temperatures. On the Green Unit, sliced turkey measured 105.1 degrees Fahrenheit and was described as salty, pale, and unappealing; mashed potatoes measured 122.7 degrees Fahrenheit and lacked flavor; vegetables measured 105.8 degrees Fahrenheit and were watery, mushy, and flavorless; milk measured 51.3 degrees Fahrenheit; and orange drink measured 57.7 degrees Fahrenheit. Similar findings were recorded on the Yellow Unit, where turkey measured 100 degrees Fahrenheit and vegetables 116 degrees Fahrenheit, and on the Blue Unit, where turkey measured 110 degrees Fahrenheit and brussels sprouts measured 120 degrees Fahrenheit. The Food Service Director acknowledged during the observations that the temperatures for the hot foods were low and that hot foods were expected to be served between 130 and 140 degrees Fahrenheit, while cold foods were expected to be below 40 degrees Fahrenheit. The Director also stated the turkey should have been served hotter and the brussels sprouts warmer. The Director of Nursing stated they were not aware of the cold food complaints and were unsure of the exact serving temperatures for hot and cold foods, though they would be concerned about foodborne illness if foods were not maintained at proper temperatures.
Food Storage, Labeling, and Kitchen Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the Main Kitchen and one Nourishment Room. During observation of the Main Kitchen, surveyors found multiple food items in the reach-in cooler and walk-in cooler that were undated, unlabeled, or outdated, including a half-eaten dessert with no name or date, a half-full container of Mexicali dip with no identifying information, chicken broth dated 11/21/2025, cheese dip with no date, trays of pudding cups and other nourishments with no dates, wrapped sandwiches with no dates, sliced meats with dates that were expired or questionable, and opened hot dogs and raw hamburgers without dates. The Food Service Director stated that trays of food in the walk-in cooler should have dates and that items older than three days, except breads, should be discarded. The Food Service Director also stated opened hot dogs and hamburgers should have been labeled with the date they were removed from original packaging. The Main Kitchen also had sanitation and food service concerns. A window air conditioning unit in the food preparation area had visible dust on the louvers and dust on the windowsill below. A bucket of water was placed under plumbing near the automatic dishwasher because water was dripping from the plumbing. The Maintenance Director observed the leak and stated they were not aware of it, while the Food Service Director stated a work order had been entered previously for a kitchen plumbing leak. During lunch tray preparation, [NAME] #1 was observed not wearing a beard cover while preparing residents' lunch trays. [NAME] #1 stated they should have been wearing a beard guard, and Dietary Aide #1 and the Food Service Director both stated staff with facial hair should wear beard guards so hair does not get into food. In the [NAME] Unit Nourishment Room, the refrigerator contained multiple items that were not properly labeled or dated, including chicken nuggets in a pizzeria box, iced tea in a pitcher, opened orange juice, garlic bread, a plate of food labeled only with a resident's name and no date, and a foil container of ravioli with no name or date. A bag labeled with a resident's name and room number contained macaroni and cheese and ham, but neither the outer bag nor the inner container had a date. Another item of beans was labeled with a resident's name and dated 11/27/2025. The Food Service Director stated food in Nourishment Room refrigerators should be kept for no more than three days and that food without a date would be discarded if the resident could not identify when it was brought in. The DON stated Nourishment Room refrigerator food always needed the resident's name and date and had to be used within three days.
Unsanitary and Damaged Resident Areas
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable interior across three resident units, with multiple observations showing stained, dirty, damaged, or unsanitary conditions in resident rooms, shower rooms, and bathrooms. On the Yellow unit, privacy curtains in a resident room were observed discolored and soiled with dark marks and black debris. The Maintenance Director stated the curtains needed to be washed, and later stated there was only one spare curtain for the entire facility and more had not yet been ordered. A housekeeper stated the curtains were probably stained and that the condition was not homelike. On the Blue unit, a resident’s toilet seat in the bathroom was loose and moved several inches side to side when pushed, and the resident stated it bothered them. In the shower room, there were small black fuzzy balls that appeared to be hair on the floor, debris on the wall and floor, and a ceiling tile above the shower stall that was bowed, damp, soft, and discolored. A CNA stated the shower stall should have been cleaned after use and that the ceiling tile had been bowed and discolored for about four months. The Unit Manager stated housekeeping was responsible for cleaning the shower stall walls and floors, and the Regional Plant Operations Director later poked the ceiling tile and his finger went through it, confirming it was damp. On the Green unit, residents were observed with oxygen concentrators whose exterior surfaces and filters were covered in thick gray dust. A resident’s shared bathroom lacked paper towels and had multiple unlabeled used body wash and lotion bottles on the sink ledge; another resident’s bathroom also lacked paper towels and had personal items stored there. The shared bathroom floor was tacky, had a malodorous urine odor, and dirty black grout lines. A resident’s air mattress cover was ripped and peeling, exposing a large brown/red stained area, and the resident stated the mattress did not hold air and had been like that for 2 to 3 weeks. In the shower room, there were unlabeled used body wash bottles, hair on the floor and in the drain, debris and candy wrappers on the floor, and no disinfectant available for sanitizing. Staff interviews showed uncertainty and inconsistency about who was responsible for cleaning oxygen concentrators, shower areas, and related equipment, and the DON stated there was no scheduled cleaning for oxygen concentrators and filters.
Infection Control Failures During Wound Care, Transfers, Medication Passes, and Vaccination Signage
Penalty
Summary
The facility failed to maintain an infection prevention and control program during observations, interviews, and record review involving residents with wounds, indwelling devices, and enhanced barrier precautions. Resident #4 had diagnoses including congestive heart failure, diabetes mellitus, and a sacral pressure ulcer, and was documented as having an indwelling catheter, a colostomy, and a stage 3 pressure ulcer. During wound care, the resident’s soiled brief and wound dressing were removed and the brief was placed directly on the floor without a barrier. Staff later stated soiled linen or briefs should not be placed on the floor and that a barrier should have been used. Resident #41 had diagnoses including paraplegia, major depressive disorder, and contracture of the left forearm, and was documented as cognitively intact, dependent for toileting hygiene, bathing, and transferring, and on enhanced barrier precautions for infection risk related to comorbidity infection. During observation, staff transferred the resident from a shower bed to the bed and later provided wound care without wearing the required precaution gown. Enhanced barrier precaution signage was posted outside the room, but staff stated they forgot to wear gowns during showering, transferring, incontinent care, and wound care. The resident’s wound was documented as a full thickness wound with drainage and macerated peri-wound skin. During medication administration for Resident #19, an LPN dispensed medications into the palm of their bare hand, then placed medications into a souffle cup after some fell onto the medication cart and were picked up with ungloved fingers. The medication cart also had personal beverages on top of it during medication administration. In addition, intermittent observations found no conspicuous signage throughout the facility offering COVID-19 vaccinations/boosters, and the DON/Infection Preventionist stated they were not aware that such signage needed to be posted. The report also cites facility policies requiring proper handling of oral medications, clean medication storage areas, enhanced barrier precautions with gowns and gloves for high-contact care, and conspicuous COVID-19 vaccination signage.
Unassessed Self-Administration of Bedside Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed by the interdisciplinary team to determine whether self-administration of medications was clinically appropriate and safe. Resident #77 had diagnoses including a right femur fracture, atrial fibrillation, and an anxiety disorder, and the MDS documented that the resident was cognitively intact and understood information. The care plan identified the resident as independent for decision-making, but there was no documented evidence that the resident was assessed for the ability to self-administer medications. The resident had an order for diphenhydramine hydrochloride 25 mg, 2 tablets by mouth at bedtime, and the medication profile reflected diphenhydramine hydrochloride for sleep management. However, there were no physician orders for self-administration or for medications to be kept at the bedside, and progress notes and provider notes contained no documentation that the resident had been evaluated for safe self-administration or bedside storage. During observations, an opened bottle of max strength sleep aid diphenhydramine hydrochloride 50 mg was seen on the resident’s tray table and remained visible from the doorway on a later observation. During interview, the resident stated they took the diphenhydramine occasionally to sleep, brought it from home, and that the facility let them take it by themselves. The resident also stated they had taken it the prior night and later placed the bottle in the nightstand drawer. Staff interviews confirmed that residents were not supposed to self-administer medications or keep them at the bedside without an order, and that bedside medications were a safety concern. The DON stated there was a process for self-administration that required provider determination, an order, consent, education, and a lock box, and stated the facility was unaware the resident had medications at the bedside.
Resident Preferences for Showering and Morning Rising Were Not Honored
Penalty
Summary
The facility failed to honor resident choice and self-determination for two residents whose preferences were documented in their records. One resident was cognitively intact, dependent on staff for bathing, and had a care profile indicating a weekly shower on Wednesdays during the afternoon shift. Although the resident stated they had showered nightly at home and asked staff when they would get a shower, the record showed only bed baths or refusals on shower sheets, with no progress note documentation of shower refusals. Staff interviews revealed that aides did not provide a shower because they believed the resident could not fit in the shower bed or shower chair, and they did not report the issue to nursing leadership. The second resident was cognitively intact and had a documented preference to get out of bed early, by 7:00 AM on the night shift. The care plan and care profile identified this preferred rise time, and the resident stated they wanted to be up before breakfast and had told the Unit Manager. However, observations showed the resident remained in bed during morning checks, and progress notes did not document refusals to get up at the preferred time. Staff stated the resident was not treated as an early get-up and that staffing limitations sometimes prevented them from assisting the resident out of bed when requested. Interviews with nursing staff and leadership confirmed that the resident’s stated preference to rise early was known, but was not being followed. The LPN Manager stated the resident’s preference was documented and that staff were expected to follow the care plan, but also acknowledged the resident was not being assisted out of bed by the preferred time due to staffing. The DON stated resident preferences were obtained on admission, could be updated, and should be honored, and after reviewing the care profile confirmed the resident’s preferred rise time was by 7:00 AM and that staff should have attempted to get the resident up at that time.
Failure to Provide Required Nail Care
Penalty
Summary
The facility failed to ensure that residents who were unable to complete activities of daily living received the necessary nail care to maintain good grooming for two residents reviewed. The deficiency involved Resident #44 and Resident #5, both of whom had impaired self-care needs and required staff assistance with personal hygiene. The facility policy stated that nail care included daily cleaning and regular trimming on the resident’s bath or shower day, and that nail care was still to be provided if a resident refused a bath or shower. Resident #44 was admitted with right hemiplegia, cerebral infarction, and aphasia. The resident’s assessment documented moderate cognitive impairment and the need for some assistance with ADLs. The care plan identified impaired self-care function but did not address nail care. Although a progress note from 08/19/2025 documented that the Assistant Director of Nursing trimmed long, thick fingernails, later observations on 12/02/2025 and 12/03/2025 showed long fingernails on the resident’s right hand, including one-inch-long nails and a contracted right hand with three fingers having one-inch-long nails. The resident stated they could not cut their own nails because of the stroke, that the nails bothered them, and later indicated they wanted them trimmed. Staff interviews confirmed the nails should not have been that long and that nail care should be reapproached if refused, but there was no documentation of refusal in the record. Resident #5 had diagnoses including diabetes mellitus, chronic kidney disease, and congestive heart failure. The resident’s assessment documented moderate cognitive impairment and dependence on staff for bathing and substantial assistance with personal hygiene. The care plan and care profile identified the bathing schedule but did not document nail care needs for a diabetic resident, although a physician order required an LPN to cut fingernails weekly on Wednesdays. The treatment record showed fingernails were not cut on 11/12/2025 and 12/03/2025, and there were no refusals documented. Observations on 12/01/2025, 12/03/2025, and 12/04/2025 showed fingernails extending beyond the finger pads on both hands, approximately 1/2 to 1 inch long, jagged, and with thick dark brown debris under the nails. The resident stated they would be okay if staff cut and cleaned them. Staff interviews and the DON’s interview confirmed the nails should have been cut and cleaned on shower day, that diabetic nail care was the nurse’s responsibility, and that refusals should have been documented, but the record did not show that nail care was completed or refused.
Failure to Provide Timely Pain Management and Skin Tear Care
Penalty
Summary
Resident #145, who had Alzheimer’s disease, repeated falls, and type 2 diabetes, sustained an unwitnessed fall and was found on the floor with bruising to the left scapula area. The fall report documented that ice was applied and acetaminophen was given per resident request, and the nurse practitioner was notified the same day with no new orders. The resident later complained of severe left shoulder pain, rated 10/10, and requested an x-ray, but the nurse supervisor documented telling the resident that x-rays were not being done because it was a holiday. There was no documented evidence that the medical provider was notified of the resident’s pain level or request for an x-ray at that time. The resident did not receive a pain medication order until several days later, and the x-ray order was not entered until after the delay, with the radiology report later showing a recent distal clavicle fracture. Resident #8, who had diagnoses including dementia, hypertension, and a right femur fracture, was assessed as severely cognitively impaired and dependent for transfers and bed mobility. The resident had a documented risk for impaired skin integrity and staff were expected to check skin with routine care each shift. A skin tear was observed on the resident’s right posterior forearm, measuring approximately 6 cm by 1 cm, with a pale yellow moist wound bed and no drainage. The resident stated the area was healing and did not know how it occurred. A CNA stated the skin tear happened during a transfer on shower day and that it had been reported to a nurse. Despite the reported injury and the visible wound, there was no documented assessment or treatment for the skin tear in the progress notes for the period reviewed, and no treatment order was present until later. The nurse who observed the wound stated they were not aware of the skin tear and should have been informed. The DON, acting as unit manager, stated skin tears should be measured, treated, and reported, and that an accident/incident report should be completed, but there was no assessment, treatment, or incident report documented for the injury.
Failure to Implement Recommended Pressure-Relieving Mattress
Penalty
Summary
Resident #4 did not receive the pressure ulcer care and pressure-relieving support recommended by the Physician Wound Consultant. The resident had diagnoses including congestive heart failure, diabetes mellitus, and a sacral pressure ulcer, and the Minimum Data Set documented the resident was cognitively intact and required partial/moderate assistance with bed mobility and transfers. The comprehensive care plan identified impaired skin integrity related to decreased mobility, diabetes, and a Stage 3 coccyx pressure ulcer, with interventions including pressure relief devices and weekly skin checks. The wound consultant’s 10/31/2025 assessment documented a Stage 3 coccyx pressure ulcer and recommended an air mattress and pressure reduction cushion. The recommendation for an air mattress was not implemented for the resident during the period reviewed. The care plan was not revised to reflect use of an air mattress until 12/05/2025, and the Care Profile was not updated to reflect it. Review of interdisciplinary progress notes from 10/31/2025 through 12/04/2025 found no documented evidence that an air mattress had been placed, and there were no resident refusals documented. During observations on 12/01/2025, 12/02/2025, 12/03/2025, and 12/04/2025, the resident was seen in bed on a regular standard mattress with no air mattress present. The resident’s wound status worsened during this period. A 11/28/2025 wound assessment documented decline of the coccyx ulcer and a new Stage 3 pressure ulcer to the left posterior thigh with an onset date of 11/27/2025. The wound consultant stated air mattresses were recommended for any Stage 3 or Stage 4 pressure ulcers and that there was no documentation the resident refused one. The DON stated the recommendation was overlooked and should have been implemented, and the charge nurse stated they could not recall why the air mattress was not placed.
Failure to Administer Synthroid as Ordered
Penalty
Summary
The facility failed to ensure that Resident #7 received Levothyroxine Sodium (Synthroid) as ordered, resulting in a deficiency. Resident #7, who was admitted with diagnoses including hypothyroidism, celiac disease, and chronic kidney disease, did not receive their prescribed Synthroid medication on multiple occasions in January 2025. The medication was scheduled to be administered daily at 6:30 AM, but it was not given on several dates, and there was no documentation or physician notification regarding the missed doses. Interviews with the resident, family members, and nursing staff revealed that the medication was often unavailable or not located in the medication cart. Licensed Practical Nurses and Registered Nurses involved in the resident's care were unaware of the medication's unavailability and did not notify the physician or document the reasons for the missed doses. The facility's medication dispensing system did not contain the required dosage of Synthroid, and the medication was not properly tracked or stored, leading to confusion among the nursing staff. The Director of Nursing and other supervisory staff were not informed of the medication issues, and there was a lack of communication and documentation regarding the missed doses. The physician was only notified after several doses were missed, and adjustments to the administration time were made without addressing the underlying issue of medication availability. This lack of adherence to professional standards of practice resulted in the resident not receiving necessary treatment as ordered.
Deficiency in Nutritional Adequacy and Menu Review
Penalty
Summary
The facility was found to have deficiencies in meeting the nutritional needs of its residents during a complaint investigation. Observations revealed that the facility's menus and nutritional adequacy did not align with established national guidelines, and the menus were not reviewed by a dietitian or other clinically qualified nutrition professional. Specifically, during lunch and dinner observations, it was noted that the protein portions provided were insufficient, with only 2 oz of protein being served, which is below the recommended 3-4 oz per meal. The investigation highlighted that the facility lacked standardized recipes, and the dietary staff prepared meals based on their training and personal knowledge rather than documented guidelines. The Dietary Supervisor and other staff members were observed plating meals without intervention from the Acting Dietary Department Director, who also made independent decisions regarding meal alternatives without consulting residents' preferences. The facility's dietitian was unaware of any written nutrient guidelines and assumed that the dietary staff knew the proper scoop sizes for plating food. Further interviews revealed that the facility's corporate menus, last reviewed in the summer of 2024, omitted the nutritive value of foods, and the facility did not maintain written nutrient guidelines. The Regional Registered Dietician noted that the facility did not utilize a software program for nutritive analysis, which could have been obtained through other means. The deficiency was compounded by the lack of individualized menu distribution to residents and limited meal alternatives, which were often leftovers or items available in the refrigerator.
Failure to Accommodate Dietary Needs
Penalty
Summary
The facility failed to provide food that accommodated the allergies, intolerances, and preferences of three residents, leading to a deficiency. Resident #7, who was on a no added salt renal, gluten-free diet, was not provided with gluten-free products and food preference choices. Despite being cognitively intact and having a comprehensive care plan that documented their dietary needs, Resident #7 repeatedly received meals that did not meet their dietary restrictions, such as tuna fish with mayonnaise instead of the preferred chicken breast, and breaded fish which they could not consume due to their celiac disease. Resident #1 and Resident #2 also did not receive meals according to their preferences. Resident #1 expressed a dislike for tacos and fish, yet these were served, prompting their family to order meals from an outside source. Resident #2 reported dissatisfaction with the vegetables and meals served, which did not align with their documented preferences of disliking spicy foods, rice, and fish. Interviews with facility staff revealed systemic issues in the dietary department, including a lack of communication and understanding of residents' dietary needs. The Acting Dietary Department Director admitted to not ordering gluten-free products due to budget constraints and a lack of awareness of specific resident requests. The Registered Dietician and other staff members acknowledged the failure to provide the necessary dietary accommodations, and the facility's administration was unaware of these issues until they were brought to their attention during the investigation.
Failure to Honor Resident's Shower Preference
Penalty
Summary
The facility did not allow a resident to choose activities, schedules, and health care consistent with their interests, assessments, and plan of care. Specifically, a resident with severe morbid obesity, multiple sclerosis, and fragile X syndrome was given a bed bath instead of a shower as planned and per their stated preference. The resident's care plan documented a preference for showers twice a week, but the care profile and shower schedule were inconsistent, and the facility was unable to provide evidence that showers were provided per the resident's care plan. Interviews with staff revealed that the resident was given bed baths because the shower chair on the unit was deemed unsafe for their weight. The Unit Manager acknowledged the issue but stated that the previous administration had not addressed it. The Environmental Director confirmed that a bariatric shower chair that could accommodate the resident's weight was available on another floor. Despite the resident's expressed preference for showers, the care plan was not updated, and the resident continued to receive bed baths instead of showers.
Non-Compliance with Carbon Monoxide Detector Maintenance
Penalty
Summary
The facility was found to be non-compliant with Section 915 of the 2020 Fire Code of New York State, which mandates carbon monoxide detection in buildings with fuel-burning appliances and ongoing preventative maintenance of carbon monoxide detectors. During a building tour, it was observed that the facility had Brand A single-station battery-operated carbon monoxide detectors in various locations, including resident unit corridors, the Main Kitchen, and the Laundry Room. Additionally, a Brand B single-station hard-wired carbon monoxide detector was located in the Boiler Room. However, the facility failed to conduct the required testing and maintenance of these detectors as per the manufacturer's recommendations. Interviews with the Environmental Director, Maintenance Supervisor, and Maintenance Assistant revealed that the Brand A carbon monoxide detectors were installed after the last Life Safety Code survey in 2023, but no testing had been performed on them. The Maintenance Assistant was unable to identify a test button on the Brand A detectors, and subsequent testing attempts showed that some of these detectors did not produce any light or sound when tested. The Environmental Director admitted that there was no task in the automated maintenance work order system to address the testing of these detectors, and they were unfamiliar with the Brand A detectors. The Brand B detector in the Boiler Room was also not tested regularly as required. The Environmental Director acknowledged the importance of testing carbon monoxide detectors to ensure their functionality in an actual emergency. It was noted that the Brand A detectors were not mechanically repairable, and the three detectors that did not respond to testing needed to be replaced. The facility's failure to test and maintain the carbon monoxide detectors as per the manufacturer's instructions resulted in non-compliance with the applicable fire code and regulations.
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What surveyors actually found near you
We read the 157 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Buffalo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mercy Hospital Skilled Nursing Facility | 0.6 mi | ★★★★★ | 0 | 0 |
| Seneca Health Care Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Garden Gate Health Care Facility | 4.2 mi | ★★★★★ | 0 | 0 |
| Elderwood At Cheektowaga | 5.2 mi | ★★★★★ | 4 | 0 |
| Highpointe On Michigan Health Care Facility | 5.4 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.