Salamanca Rehabilitation & Nursing Center

Inspectors wroteBased on interview and record review conducted during a complaint investigation (NY00370043- 694884) completed during the standard survey completed on 12/05/2025, the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than two (2) hours after the allegation was made, to the administrator and to the state survey agency for two (2) (Residents #10 and #120) of three (3) residents reviewed. Specifically, facility staff did not report alleged sexual abuse to the administrator immediately which resulted in not reporting to the state survey agency within the required time frames.

Inspectors wroteBased on observations, interviews, and record review conducted during a Standard Survey completed on 12/05/2025, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living received the necessary services to maintain grooming and personal hygiene for 1 (one) (Resident #8) of five (5) residents who were reviewed for activities of daily living. Specifically, Resident #8 who was dependent on staff for all Activities of Daily Living was not provided with timely incontinent care. Additionally, infection control practices were not maintained during care. The finding is:The policy and procedure titled Toileting, dated 03/07/2022 documented it is the policy of the facility to provide all residents with timely, person centered assistance for toileting that maintain dignity, promotes independence, and supports continence to the greatest extent possible. [...]

Inspectors wroteBased on observation, interview and record review during a Standard Survey completed on 12/05/2025, the facility did not ensure that all residents remained free of accident hazards as is possible, and each resident received adequate supervision to prevent accidents for one (1) (Resident #19) of five (5) residents observed for accidents. Specifically, the facility did not identify a potential hazard that Resident #19 had an e-cigarette/vape device stored in their room. Additionally, there was no order for use of an e-cigarette/vape, no care plan interventions for its use, and no assessment by the interdisciplinary team to ensure safe storage of the device. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 12/05/2025, the facility did not store all drugs and biologicals in locked compartments for one (1) unit (2 West) of three (3) units reviewed for medication storage. Specifically, medications for Resident #21 were left unattended and unsecured on an over the bed table in their room. The finding is: The policy titled Self-Administer of Medications reviewed 03/2025 documented staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration. Resident #21 had diagnoses including hypertension (high blood pressure), congestive heart failure (a chronic condition where the heart is too weak to pump blood), and anxiety disorder. [...]

Inspectors wroteBased on interview and record review during the Standard survey completed on 12/05/2025, 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, five (5) employees (Certified Nursing Assistant #10, Housekeeper#1, Certified Nursing Assistant #11, Licensed Practical Nurse #5, and Certified Nursing Assistant #12) of ten (10) employees that were subject to the New York State Nurse Aide Registry Verification, were not reviewed through the New York State Nurse Aide Registry prior to their employment as required.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 9/1/23, it was determined that the facility did not ensure that the resident environment remains as free of accident hazards as is possible. Specifically, three (1 West, 2 East, 2 West) of three resident units had water temperatures that exceeded 120 degrees Fahrenheit (°F).

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 9/1/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one Main Kitchen. Specifically, the dishwasher was not functioning properly and there was a lack of proper hand hygiene. The policy and procedure titled FOOD PREPARATION AND SERVICE dated 5/2/23 documented that appropriate measures were used to avoid cross contamination, including cleaning and sanitizing food-contact equipment between uses, and that food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illnesses. The policy and procedure also documented that bare hand contact with food was prohibited. Gloves were worn when handling food directly and changed between tasks. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 9/1/23, the facility did not ensure that a resident, with an indwelling suprapubic catheter (tube inserted into the bladder, through the abdomen, to drain urine), received appropriate care and services to prevent urinary tract infections (UTIs) to the extent possible for one (Resident #69) of two residents reviewed for catheter care. Specifically, there was no documented evidence that the catheter was irrigated when the resident had little to no output and the physician/provider was not notified of complications with catheter and low urinary outputs. The finding is: The policy and procedure (P&P) titled Change in Status Notification effective 6/15/21 documented, the resident's attending physician will be notified by the Nurse Manager/Nursing Supervisor/Designee when: [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 9/1/23, 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 two (Units 2 [NAME] and 2 East) of two test trays. Specifically, food and beverages were served at suboptimal temperatures and were not palatable. Residents #26, #52, #72, and #91 were involved.

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 9/1/23, 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 Report of Nursing Staff Directly Responsible for Resident Care form did not include the total actual hours worked for Registered Nurses (RN), Licensed Practical Nurses (LPN) and Certified Nursing Aides (CNA) for each shift. The finding is: The policy and procedure (P&P) titled Posting Direct Care Daily Staffing Numbers effective 2/11/2017 documented shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 7/30/21, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Main Kitchen had issues with unacceptable dish washer temperatures when cleaning and sanitizing resident dinnerware and flatware, not properly cleaning and sanitizing the food processer equipment in between each food item that was being pureed, and staff not wearing beard guards while prepping and serving food.

Inspectors wroteBased on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY00262897) completed during the Standard survey 7/30/21, the facility did not ensure that each resident received adequate supervision to prevent accidents for one (Resident #5) of four residents reviewed. Specifically, the facility did not identify and reassess a resident with exit seeking behaviors and the resident eloped from the facility. The finding is: A facility policy and procedure titled, Elopement Prevention and Search for Missing Resident revised 3/10/21 documented that residents will be maintained in a safe and secure manner and protected from actual harm while encouraging a restraint free environment. Residents will be assessed for potential elopement on admission, re-admission, quarterly and upon significant change, and if an attempted elopement occurs. [...]

Inspectors wroteBased on observation, record review, and interview conducted during a Standard survey completed on 7/30/21, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, two (Main Dining Room Servery and One West) of two test trays completed for food temperatures during meals had issues involving food and beverage items that were not at safe and appetizing temperatures. Residents (#13, 15, 89, and 312) were involved.

Inspectors wroteBased on observation, interview and record review conducted during a Recertification survey completed on 7/30/21, the facility failed to ensure that infection control practices and procedures were maintained to provide a safe, sanitary, and comfortable environment to help prevent the development of COVID-19 and transmission of communicable diseases and infections. Specifically, staff member Registered Nurse (RN #2) did not wear an N95 mask, gloves, gown, and their surgical mask was below the nares during specimen collection for one Visitor (#1) of three visitors tested for COVID-19. The finding is: A CMS (Centers for Medicare and Medicaid Services) memorandum, revised 4/27/21 (Reference QSO-20-38-NH), documented: [...]