BUFFALO, N.Y. — New York state has imposed its maximum allowable fine of $10,000 on Emerald South Nursing and Rehabilitation Center after an 87-year-old dementia unit resident fell 34 feet to his death from a third-floor window in June, according to a state Health Department inspection report. Staff at the Buffalo facility had received multiple warnings that the resident, William Strasner, was repeatedly removing safety screws designed to prevent windows from opening more than five inches.
What Inspectors Found
The state Health Department's investigation revealed a troubling chain of failures leading to Strasner's death, as reported by the Buffalo News. The facility's director of maintenance told inspectors that he had warned both the nursing home's administrator and nursing staff leaders that Strasner was repeatedly removing the window safety screws, according to the inspection report. Maintenance workers installed bolts on Strasner's window 10 times after his arrival at the facility, but staff could not determine how he was removing them.
Strasner had been homeless and was diagnosed as lacking decision-making capacity when he was discharged from a hospital to Emerald South, according to the report. A nurse at the hospital identified Strasner in his admission paperwork as being at risk for elopement — the clinical term for a resident leaving or attempting to leave a facility without authorization. Despite that documented risk, staff did not place a wander-guard elopement bracelet on his wrist that would have triggered an alert if he moved toward an exit or window, according to the inspection findings.
The resident was described as difficult to care for in the inspection report. He refused all hands-on care and medications, would not change his clothes or shower, and frequently stated "I'm going out of here," according to a social worker's notes documented in the report. During a psychiatric evaluation at the facility, Strasner told evaluators, "I didn't do no crime so I don't know why they hijacked me and put me here," according to the state's findings.
Yet inspectors determined that Strasner's care plan did not include any strategy for preventing elopement. While the care plan documented that he believed he was in jail, it contained no method for monitoring his whereabouts or movements, according to the report. A certified nursing aide arriving for her shift discovered Strasner on the ground outside the building. He had used a makeshift rope fashioned from bedding to climb out of his third-floor window.
CMS Inspection History
Federal records paint a picture of a facility with deep, systemic problems well before Strasner's death. The Centers for Medicare and Medicaid Services currently rates Emerald South Nursing and Rehabilitation Center at just 1 out of 5 stars overall — the lowest possible rating. The facility also holds a 1-star rating for health inspections and a 1-star rating for staffing, indicating persistent deficiencies in both regulatory compliance and workforce levels. Its quality measures score of 3 stars is the sole metric at or above average.
Strasner's death was not an isolated tragedy at the 122-bed, for-profit facility. Another resident, Ruth Murray, was beaten to death inside Emerald South in 2017, and the state levied the same maximum $10,000 fine for violations related to that death, according to the Buffalo News.
The facility was part of a broader pattern identified in regional reporting. A 2019 Buffalo News investigation found that 17 of the 46 nursing homes in Erie and Niagara counties had been purchased over the preceding 11 years by out-of-town investors, and most of those homes ranked among the worst-rated in the region, according to that report. The federal government at one point rated Emerald South as a two-star — or "below average" — nursing home.
Ownership & Operations
Emerald South had been operated since 2012 by a company owned by Judy Landa, a Long Island resident with no prior healthcare experience who was described as only a passive investor, according to reporting by the Buffalo News. The state ultimately appointed a receiver — Grand Healthcare System of New York City — to take over operations of both Emerald nursing home facilities in late October 2019, authorizing the receivership for up to 18 months.
The facility has since closed, and the property has been donated to a religious organization, according to the Buffalo News. The closure of Emerald South represents the end of a facility whose history was marked by resident deaths, regulatory failures, and absentee ownership — a combination that federal and state regulators have increasingly scrutinized across the for-profit nursing home sector.
The $10,000 maximum fine — while the steepest penalty available to New York state — has drawn criticism from patient advocates who argue that such limits are insufficient to deter negligence at facilities generating significant revenue. Federal regulations require nursing homes to develop comprehensive care plans that address identified risks, including elopement, and to implement interventions appropriate to each resident's assessed needs.
Resources for Families
Families with concerns about care at any New York nursing facility can contact the New York State Long-Term Care Ombudsman program at 1-855-582-6769. The ombudsman program advocates for residents and can investigate complaints about care quality, safety, and resident rights.
Nationally, the Administration for Community Living operates the Eldercare Locator at 1-800-677-1116, which connects callers with local ombudsman programs and aging services in every state. Additional resources and guidance on selecting and monitoring nursing home care are available at [ltcombudsman.org](https://ltcombudsman.org).
Families can also review any facility's inspection history, staffing data, and quality ratings through the CMS Care Compare tool at medicare.gov, which provides federally collected data on every certified nursing home in the country.