Salamanca Rehabilitation & Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.The findings are:The policy titled Abuse- Investigation, Protection and Reporting, dated 10/24/2022, documented that abuse will be thoroughly investigated and promptly reported to local, state and federal agencies. All reports of an alleged violation of abuse will be reported immediately, but not later than (2) two hours after the allegation.Resident #10 had diagnoses including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Residents are to be assessed for voiding patterns and care planned appropriately. Timely Response: answer call lights promptly, anticipate needs at predictable times (e.g., wake-up, after meals,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The finding is:The policy titled Resident Safety and Accident Prevention dated 03/2025, documented the facility is committed to providing a safe and supportive environment for all residents by implementing a structured, proactive accident prevention program. The program focuses on identifying and addressing both individual and environmental factors that could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The Minimum Data Set (resident assessment tool) dated 09/05/2025 documented Resident #21 was understood, understands and was cognitively intact. The comprehensive care plan dated 05/09/2025 documented Resident #21 would make choices as able. The care plan lacked documented evidence that Resident #21 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). The findings are: The policy and procedure titled Daily Domestic Hot Water Testing effective date 2017, with a reviewed date of 8/2023 documented this policy outlines the daily testing of the domestic hot water supply to ensure it is regulated within 90 - 120 °F. Maintenance staff shall perform daily testing at all floors using a correctly calibrated thermometer. This gauge may be a digital or dial type and shall be tested weekly by comparison to other known correctly calibrated gauges. Water temperatures are to be taken on each resident unit daily, at varying times, at two separate locations. One at the beginning of the hot water circuit and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Disposable gloves were single-use items and discarded after each use. The policy and procedure PREVENTATIVE MAINTENANCE dated 6/2022 documented only routine maintenance safety inspections to ensure resident safety and to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: any situation which requires a change in the resident's plan of care, medication, or treatment regimen; including the following - intake and output…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: The policy and procedure titled Food Preparation and Service dated 5/2/23 documented that the danger zone for food temperatures is between 41 degrees (°) Fahrenheit (F) and 135°F. Therefore, foods must be maintained below 41°F or above 135°F. The policy and procedure further documented the temperatures of foods held in steam tables were monitored throughout the meal. The facility Recipe Card for Macaroni Salad documented to chill the macaroni in a 2 (inch) deep container to 41ºF or below. The recipe card then documented to hold on ice for service, maintaining temperature at 41ºF or below for up to 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: Review of the facility Policy and Procedure (P&P) entitled Food and Nutrition Services dated 3/10/21 documented each resident is provided with a nourishing, palatable, well balanced diet that meets his or her nutritional and specialty dietary needs. All surfaces will be sanitized with approved sanitizing agent between food preparation efforts including sanitizing all small equipment. Review of the facility P&P entitled Dietary Dress Code dated 3/10/21 documented employees of the dietary department…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. If residents were identified as being a wanderer and/or exhibited the potential for elopement, a behavior management plan would be developed. All staff would receive elopement prevention in-service upon hire and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: Review of the undated Policy and Procedure (P&P) entitled Food Temperatures dated 3/2021 documented to ensure safety and quality of food items, it is the policy of the facility to obtain and record temperatures of food items prior to serving to residents. Hot foods must reach an internal temperature of 145°F (degrees Fahrenheit) and allowed to rest for at least 3 minutes before consuming. Cold foods should be held below 40°F. During an interview on 7/26/21 at 11:38 AM Resident #312 stated the food usually comes up cold and could be warmer. Trays are late. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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: during COVID-19 specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown when collecting specimens. CDC (Centers for Disease Control and Prevention) guidance, updated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.