The deficiency was cited as causing minimal harm or the potential for actual harm, and affected a small number of residents.
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Resident #1 had been admitted to the facility with a diagnosis of generalized anxiety disorder.
When inspectors visited on April 14, 2025, they found Resident 30 lying in bed with a pair of eyeglasses sitting on the overbed table nearby.
The citation, recorded under F0578, covers the facility's handling of records at admission.
The inspection, completed April 24, reviewed personnel files for five staff members.
Two residents, identified in inspection records as Resident #740 and Resident #306, had each experienced significant weight loss.
That finding sits at the center of a federal inspection completed April 18, 2025, at the facility on West Seneca Turnpike.
When the wrong people are in the room, or the right people are not in the room at all, those decisions rest on an incomplete picture.
Nearly a year of hospital transfers and discharges, and the ombudsman's office had been told about exactly one of them.
Federal inspectors documented the lapse during an April 2025 survey of the facility at 5075 West Seneca Turnpike.
The facility's own Director of Nursing confirmed the problem directly.
The inspection, completed August 11, was triggered by a complaint.