Gowanda Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Gowanda Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 21, 2026

  Based 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.The findings include:The facility policy and procedure titled Food Consistencies reviewed 01/2026 documented the facility was committed to ensuring that all residents receive meals that are prepared and served in accordance with their assessed needs, prescribed diets, and… […]

• Immediate jeopardy, isolatedF689Jul 25, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF609Jul 25, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF610Jul 25, 2023

  Based 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); a… […]

• No harm, potential for more than minimal, patternF725Jul 25, 2023

  Based 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. The findings are: 1. The Facility assessment dated [DATE] documented staffing levels were adjusted based on patient acuity and census. The total residents at the time of the facility assessment were 128 and a total capacity of 160. […]