Gowanda Rehabilitation and Nursing Center

Inspectors wroteBased on observation, interview and record review conducted during survey, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (Resident #1) of five residents reviewed. Specifically, the facility failed to provide Resident #1 with their medically prescribed diet, resulting in an avoidable choking accident. Subsequently, Resident #1 expired. This resulted in harm that is Immediate Jeopardy and Substandard Quality of Care to Resident #1's health and safety.

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 5/16/25, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for one (1) (Resident #30) of four (4) residents reviewed. Specifically, Resident #30 was not provided with the removal of unwanted facial hair. The finding is: The policy titled Activities of Daily Living - Bathing/ Grooming, dated 1/2025, documented the facility would bathe/shower/groom residents based upon their comprehensive assessment and consistent with the resident's preferences, needs, and choices. If a resident had no specific shaving preference, the facility would offer assistance with shaving as needed when unwanted facial hair was noted. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey, completed on 5/16/25, the facility did not ensure that a resident with a Foley catheter (a tube inserted into the bladder to drain urine) received appropriate treatment and services to prevent urinary tract infections for one (Resident #48) of two residents reviewed. Specifically, Resident #48, had a history of urinary tract infections and infection control practices were not maintained. The finding is: The policy and procedure titled Foley Catheter Care, dated 1/2025, documented catheter care will be provided every shift and as needed as soiling occurs. The policy and procedure titled Catheter- Positioning & Emptying of Drainage Bag, dated 2/2025, documented never allow the urinary drainage bag to touch the floor, this causes contamination. [...]

Inspectors wroteBased on observation, interviews and record review conducted during the Standard survey completed on 5/16/25, the facility did not ensure correct installation, use, and maintenance of bed rails for one (1) (Resident #3) of one (1) resident reviewed. Specifically, the half bedrails were loose, not secure per the manufacturer's recommendations, and documentation of routine inspections was inconsistent. The finding is: The policy and procedure titled General Bed Safety revised 1/2025 documented the facility is committed to promoting resident safety and preventing accidents by ensuring appropriate bed safety practices. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety. When indicated, side rail/enablers shall be installed and used in accordance with manufacturer's instructions and current best practices. [...]

Inspectors wroteBased on observation, interview, and record review conducted during an Extended Standard survey started on 7/17/23 and completed on 7/25/23, the facility did not ensure that each resident received adequate supervision to prevent accidents for one (Resident #43) of 10 residents reviewed. Specifically, the facility failed to provide adequate supervision to provide a safe environment for Resident #43, who is severely cognitively impaired with a history of resident-to-resident altercations because of unsafe wandering into other residents' rooms. Subsequently, Resident #43 had 8 documented falls from 3/4/23 to 7/21/23 and changes in the plan have been ineffective. This resulted in no actual harm with the likely hood for more than minimal harm that is Immediate Jeopardy and Substandard Quality of Care to Resident #43's health and safety. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint Investigation (#NY00311987 & #NY00310989) during the Extended survey completed on 7/25/23, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, are reported immediately and no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for four (Residents #4, #17, #76, #234) of nine residents reviewed for reporting of alleged violations. Specifically, the facility did not report to the New York State Department of Health (NYSDOH) agency within the required time frames. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint Investigation (#NY00311987 & #NY00300989) conducted during the Extended survey completed on 7/25/23, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment have evidence that alleged violations are thoroughly investigated for four of nine residents (Residents #4, #17, 76 and #234) reviewed for abuse. Specifically, a resident had a purple bruise on their elbow and forearm and did not have an investigation initiated for an injury of unknown origin (Resident #4); and the facility did not have thorough investigations that included staff statements for a resident with bruising on their left side including their cheek, rib cage, hip, and thigh (Resident #17); [...]

Inspectors wroteBased on observation, interview and record review conducted during the Extended survey completed on 7/25/23, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of one facility. Specifically, the facility did not have adequate nursing staff based on the facility's established minimum number of staff for each unit and each shift.

Inspectors wroteBased on interview and record review conducted during a Complaint Investigation (#NY00311987) during an Extended survey completed on 7/25/23, the facility did not ensure that the physician was immediately informed when there was significant change in the resident's physical, mental, psychological status for one (Resident #4) of two residents reviewed for notification of change. Specifically, the physician was not immediately notified that Resident #4 had a fractured elbow. The finding is: The policy and procedure titled, Change in Status Notification dated 6/15/21 documented that the resident's attending physician or designee will be notified when there is a significant change in the resident's condition. 1. Resident #4 was admitted with diagnoses of dementia and schizophrenia. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Extended survey completed on 7/25/23, the facility did not ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming, personal and oral hygiene for two of five residents (Resident #13 & #116) reviewed. Specifically, there was lack of oral and perineal (the groin area) care during morning care and staff did not wash their hands or change gloves after providing bowel incontinence care (Resident #13); and a resident who was dependent on staff for hygiene with facial hair was not shaved or offered to be shaved after their shower (Resident #116).

Inspectors wroteBased on observation, interview, and record review conducted during the Extended survey completed 7/25/23, the facility did not ensure that a resident, with an indwelling catheter (Foley - tube inserted into the bladder to drain urine), received the appropriate care and services to prevent urinary tract infections (UTIs) to the extent possible for two (Resident #s12 and 13) of two residents with a history of UTIs, reviewed for urinary catheters. Specifically, staff did not provide catheter care for Resident #13 and staff improperly emptied the urine drainage bags for Residents #12 and #13.

Inspectors wroteBased on interview and record review conducted during the Extended survey completed on 7/25/23, the facility did not ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician's orders and the comprehensive person-centered care plan for one (Resident #131) of one resident reviewed for peripherally inserted central catheter (PICC - a long, thin tube that is inserted through a vein in an arm and passed through to the larger veins near the heart) use. Specifically, there was no documented physician order to remove the PICC line and the PICC line was removed by a Registered Nurse (RN) who did not have any documented evidence of special training or certification. The finding is: [...]

Inspectors wroteBased on interviews and record reviews conducted during an Extended Survey completed on 7/25/23, the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for one (Resident #8) of one resident reviewed. Specifically, a Telemedicine (tele med) Psych Consult was not completed for Resident #8 as ordered by the physician for their explosive behaviors with care. The policy and procedure (P&P) titled Telehealth Services dated 4/2022 documented all residents will have access to telehealth medical, and psychiatric/psychological services. The use of electronic communication and information technologies to provide or support clinical psychiatric care at a distance. [...]

Inspectors wroteBased on interview and record review conducted during the Extended survey completed on 7/25/23, the facility did not implement an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for one (Resident #12) of one resident reviewed. Specifically, Resident #12 was receiving Cipro (an antibiotic) since 4/21/23 as a urinary tract infection (UTI) prophylaxis (prevention) without documented evidence to support its continued use, appropriate indications for its continued use, and a lack of monitoring and tracking its use by the infection preventionist (IP). The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00255554) completed during the Standard survey on 6/17/21, the facility did not provide an environment as free from accident hazards as possible and devices to prevent accidents for one (Resident #73) of three residents reviewed. Specifically, the facility did not ensure scheduled routine maintenance of positioning bars was conducted. On 3/25/20 an equipment failure of the positioning bar occurred resulting in a fall with injury. The finding is: Review of the facility policy and procedure (P&P) entitled Side Rail & Grab bar Use dated 10/17 revealed side rails will be assessed by Maintenance during the room of the day audit with all negative findings being immediately corrected. Side rails found to be loose or un-safe by staff should be immediately addressed with Maintenance. [...]