Newfane Rehab & Health Care Center

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 6/5/25, the facility did not ensure that there were housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for four (4) (Unit A, B, C, and D) out of four (4) units. Issues included foul odors (Unit A, B, C, and D); shower rooms with black/brown debris with missing tiles or tiles in disrepair and dirty linens ( Unit A, B, C, D); cracked floor tiles with missing pieces (Unit D); baseboards splattered with a white substance (Unit A); walls unfinished with spackle/primer and not painted (Unit A); toothbrushes, hairbrushes, wash basins, toothpaste, and a bed pan not labeled or clean in shared bathrooms (Unit C); and soiled floor mats (Unit D). The finding is: [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 6/5/25, the facility did not ensure that the physician signed and dated all orders for 13 (Resident # 1, 5, 9, 15, 20, 28, 20, 42, 48, 84, 92, 124, and 137) of 32 residents reviewed. Specifically, the facility did not ensure that the physician or non-physician provider evaluated the resident's current medication regimen and renewed orders in the electronic medical record (EMR) at least every 60 days.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 6/5/25, the facility did not ensure that residents who use psychotropic drugs received gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs for two (2) residents (Resident #42 and #129) of five (5) residents reviewed for unnecessary medications. Specifically, there were no gradual dose reductions of antipsychotic medications (Residents #42, #129) and antidepressant medication (Resident #129). Additionally, there was lack of medical provider documentation for the reason dose reductions were clinically contraindicated.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 6/5/25, the facility did not ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision to prevent accidents for one (1) (Resident #409) of one (1) resident reviewed for elopement. Specifically, Resident #409 displayed wandering and exit seeking behaviors that were not identified or evaluated for implementation of interventions for their safety. Additionally, Resident #409 had an unwitnessed fall in the shower room. The finding is: The policy titled Resident Who Wander revised 3/12/2021, documented residents who wander and who may walk unassisted or unsupervised will be care planned to do so by the interdisciplinary team. [...]

Inspectors wroteBased on observation, interviews, and record reviews conducted during the Standard survey completed on 6/5/25, the facility did not attempt alternatives prior to installing bed rails, did not ensure assessment, informed consent and review of the risk and benefits for use was conducted prior to use, and ensure the correct installation and maintenance of bed rails for four (4) (Resident #9,18,20, 29) of (4) four residents reviewed. Specifically, bedrails were loose and not secure per the manufacturer's recommendations. In addition, there was no evidence of appropriate alternatives used prior to installing the bed rails, no consent or routine preventative inspections of the side rails and incomplete documentation of education (risk/benefits).

Inspectors wroteBased on interview and record review, conducted during the Standard Survey completed on 6/5/25 the facility did not ensure they provided medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, one (1) (Resident #85) of one (1) resident reviewed wanted to return to the community did not have a referral made to an outside agency. The finding is: The policy and procedure titled Transfer and Discharge of Residents dated 2/8/2010 documented that residents are informed by the Registered Nurse Case Manager or the Director of Social Services of available community services as applicable. Residents may also be instructed when and how to obtain further care treatment. The undated document titled Nursing Home Resident's Rights documented that a resident has a right to self-determination. [...]

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 6/5/25, the facility did not ensure that the pharmacist reported irregularities to the attending physician and the facility's Medical Director, and the Director of Nursing, and that these reports were acted upon for (2) two (Residents #42 and #129) of (5) five residents reviewed. Specifically, the Pharmacy Consultant did not recommend gradual dose reductions for psychotropic medications in effort to reduce or discontinue these medications. In addition, did not request documentation from the physician to support why a GDR (gradual dose reduction) would be clinically contraindicated.

Inspectors wroteBased on interviews and record review conducted during the Standard survey completed on 6/5/25, the facility did not ensure that the resident, resident's representative(s), or ombudsman was notified of the transfer or discharge, and the reasons for the move, in writing and in a language and manner they understand for (2) two of (4) four residents (Resident #88 and #92) reviewed for hospitalization. Specifically, the facility did not complete notices of discharge or transfers when they were hospitalized on [DATE] (Resident #88), and on 5/14/25 (Resident #92). In addition, the ombudsman was not notified of the resident's transfers to the hospital.

Inspectors wroteBased on interview, and record review conducted during the Standard survey completed on 6/5/25, the facility did not ensure that comprehensive assessments, using the Minimum Data Set-(MDS-a resident assessment tool) of residents, were conducted within 14 calendar days after admission and not less than once every 12 months for two (Resident #109 and Resident #409) of two residents reviewed. Specifically Resident #109's Annual Minimum Data Set was not complete within 366 days after the assessment reference date (ARD) of the previous comprehensive assessment, and Resident #409's admission Minimum Data Set Assessment was not completed within 14 days of the assessment reference date.

Inspectors wroteBased on observation and interview conducted during the Standard survey completed on 8/11/23, the facility did not ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior were provided for four (Units A, B, C and D) of four resident units. Specifically, there were issues with strong urine odors in resident rooms, bathrooms, hallways, and reception area; crumbling drywall around windows, unpainted, patched drywall, missing and/or in disrepair baseboards; peeling wallpaper, soiled walls, dusty ceiling vents, and a torn/ripped resident mattress.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 8/11/23, the facility did not provide food and drink that were prepared by methods that conserved flavor, and appearance, were palatable and at a safe and appetizing temperature, for five (Units A, B, C, D, & Kitchen) of five test trays. Specifically, food and beverages during meals were served at suboptimal temperatures, unappetizing in appearance and were not palatable. Residents #33, #37, #58, and #113 were involved.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 8/11/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues with outdated undated food items, corner ceiling fans near prep stations observed to be dusty and greasy and were in use while food preparation was going on and Dietary Aide #1 in food preparation area with facial hair, not wearing a beard guard. In addition, three (Unit A, Unit C and Unit D) of four-unit nourishment kitchens had issues with no thermometers in the freezers and Unit A and Unit D undated opened food items and stored staff personal belongings, food, and drink items.

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 8/11/23, the facility did not maintain an effective pest control program so that the facility was free from insects. Specifically, for three (A Unit, B Unit, D Unit) of four resident units had issues with flies.

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey completed on 8/11/23, the facility did not ensure they treated each resident with dignity and respect in an environment that promotes maintenance or enhancement of their quality of like, recognizing each resident's individuality. Specifically, one (Resident #15) of two residents reviewed for dignity was not provided with their breakfast meal at the same time when other residents who eat in their rooms received their meal trays. Resident #15 was told by staff they have to wait until the dining room was served. The finding is: The undated policy and procedure (P&P) titled Dignity During Dining documented trays were to be delivered to residents in a timely manner. 1. Resident #15 had diagnoses that included end stage renal disease (ESRD, kidney disease), type 2 diabetes, and chronic pain. [...]

Inspectors wroteBased on interview and record review conducted during a Complaint Investigation (#NY00307977) during a Standard survey completed on 8/11/23, the facility did not ensure that resident and residents' representative received a written notice of transfer or discharge that contained specific required contents specified in the regulation for one (Resident #417) of one resident reviewed for facility-initiated discharge. Specifically, the notice of transfer/discharge date d 11/23/22 did not included the location to which the resident was being transferred; a statement of the residents appeal rights, including the name, address (mailing and email), a telephone number of the entity which receives such requests, information on how to obtain an appeal form, assistance in completing the form and submitting the appeal hearing request; [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 8/11/23, 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 (Residents #144) of five residents reviewed for ADL's. Specifically, Residents #144 had jagged nail edges with dark thick debris under their fingernails. The finding is: The policy and procedure (P&P) titled Bath/Shower Day dated 7/15/2014, documented to clean and cut/trim/file fingernails as needed (Nurse will provide nail care for diabetic residents). 1. Resident #144 had diagnoses that included Alzheimer's disease, type 2 diabetes mellitus, and chronic congestive heart failure (CHF). [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 8/11/23, the facility did not ensure that each resident receives adequate supervision to prevent accidents for one (Resident #160) of two residents reviewed for accidents. Specifically, a resident with a diagnosis of dysphagia (difficulty swallowing) and an order for a pureed diet (consistency of smooth, thick paste), received a sandwich and was observed eating it in their room without staff supervision. In addition, there was lack of cueing during meals for the resident to take small sips of liquids. The finding is: The undated policy and procedure (P&P) titled Summary of House Diets provided by the Assistant Administrator documented for a pureed diet, all food was pureed to a mashed potato consistency. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 8/11/23, the facility did not post on a daily basis the staff total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. Specifically, the facility's posted Daily Staffing form did not include the total number of licensed and unlicensed nursing staff directly responsible for resident care for each shift. The finding is: During observations on 8/7/23 at 9:29 AM, 8/8/23 at 8:25 AM, and 8/9/23 at 11:06 AM the Daily Staffing form documented the total hours worked by Certified Nurse Aides (CNA), Licensed Practical Nurses (LPN), and Registered Nurses (RN) for each shift. [...]

Inspectors wroteBased on interview and record review during the Standard survey completed on 6/29/21, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified 27 (eight Registered Nurses (RNs), sixteen Licensed Practical Nurses (LPNs), two Physical Therapy Aides, and one Licensed Nursing Home Administrator) of 63 licensed employees that worked in the facility and were subject to the New York State Nurse Aide Registry, had been screened through the New York State Nurse Aide Registry prior to their employment. The finding is: Per Part 415 - Nursing Homes - Minimum Standards: [...]

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 6/29/21, the facility did not ensure that all alleged violations involving abuse are reported immediately, but no later than two hours after the allegation is made, to the to appropriate officials (including the State Survey Agency) for two (Residents #53, 143) of four residents reviewed for alleged abuse. Specifically, an alleged incident of sexual abuse (#143) and a resident to resident altercation (#53, 143) was not reported timely to the New York State Department of Health (NYS DOH) within the two-hour timeframe as required.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 6/29/21, the facility did not ensure provision of a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #108) of two residents reviewed for infection control practices during wound care. Specifically, the lack of maintaining proper hand hygiene during wound care (#108). In addition, the nurse did not perform proper hand hygiene in between resident medication administration. This involved (Residents #108, 115, and 134). [...]

Inspectors wroteBased on interviews and record review conducted during the Standard Survey on 6/29/21, it was determined that the facility failed to notify the resident, the resident's representative and/or the Office of the State Long-Term Ombudsman of a facility-initiated transfer to the hospital for two (Resident's #66 and #155) of three reviewed for written notices of transfer/discharge after hospitalization.