Buffalo, NY

Delaware Oaks Center For Rehabilitation And Nursi

2-star overall rating with 2-star inspections with abuse icon flag with 11 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle

1205 Delaware Avenue, Buffalo, NY

(716) 885-3838

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

95

Certified beds

Average residents

91

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Grand Healthcare

Operator or chain grouping

Approved since

1980-04-21

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

16 facilities

Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.58

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

0.75

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.15

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.48

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.34

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

2.96

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.38

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.15

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.54

CMS adjusted RN staffing hours

Adjusted total hours

3.24

CMS adjusted total nurse staffing hours

Case-mix index

1.47

Higher values indicate more complex resident acuity

RN turnover

56%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

53%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,566

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

26.32

Composite VBP score used to determine payment impact.

Payment multiplier

0.9841

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.25

Baseline 17.74% · Performance 19.46% · Measure score 4.25 · Achievement 4.25 · Improvement 0

Healthcare-associated infections

5.23

Baseline 9.69% · Performance 7.00% · Measure score 5.23 · Achievement 2.79 · Improvement 5.23

Total nurse turnover

1.05

Baseline 50.51% · Performance 59.41% · Measure score 1.05 · Achievement 1.05 · Improvement 0

Adjusted total nurse staffing

0

Baseline 3.82 hours · Performance 3.16 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 11.52%
10.72%
0.8 pts worse
No Different than the National Rate · Eligible stays 162 · Observed rate 13.58% · Lower 95% interval 8.41%
Discharge to community 41.06%
50.57%
9.5 pts worse
Worse than the National Rate · Eligible stays 131 · Observed rate 29.77% · Lower 95% interval 33.73%
Medicare spending per beneficiary 1.16
1.02
0.1 pts worse
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 142 · Denominator 142
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 142
Discharge self-care score 73.56%
53.69%
19.9 pts better
Numerator 64 · Denominator 87
Discharge mobility score 67.82%
50.94%
16.9 pts better
Numerator 59 · Denominator 87
Pressure ulcers or injuries, new or worsened 4.93%
2.29%
2.6 pts worse
Numerator 7 · Denominator 142 · Adjusted rate 5.03%
Healthcare-associated infections requiring hospitalization 7%
7.12%
0.1 pts better
No Different than the National Rate · Eligible stays 76 · Observed rate 7.89% · Lower 95% interval 3.86%
Staff COVID-19 vaccination coverage 0.58%
8.2%
7.6 pts worse
Numerator 1 · Denominator 172
Staff flu vaccination coverage 5.52%
42%
36.5 pts worse
Numerator 10 · Denominator 181
Discharge function score 74.71%
56.45%
18.3 pts better
Numerator 65 · Denominator 87
Transfer of health information to provider 100%
95.95%
4 pts better
Numerator 49 · Denominator 49
Transfer of health information to patient 100%
96.28%
3.7 pts better
Numerator 48 · Denominator 48
Resident COVID-19 vaccinations up to date 55.17%
25.2%
30 pts better
Numerator 48 · Denominator 87

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.5
1.7
0.2 pts better
1.9
0.4 pts better
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 3.0
1.3
1.7 pts worse
1.8
1.2 pts worse
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.9 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 97.4%
91.2%
6.2 pts better
93.4%
4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 98.5% · Q3 97.4% · Q4 96.1% · 4Q avg 97.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 96.3%
95.3%
1 pts better
95.5%
0.8 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.3%
Percentage of long-stay residents experiencing one or more falls with major injury 3.6%
3.0%
0.6 pts worse
3.3%
0.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 5.9% · Q3 1.3% · Q4 1.3% · 4Q avg 3.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 7.3%
18.5%
11.2 pts better
11.4%
4.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 6.6% · Q3 5.4% · Q4 8.6% · 4Q avg 7.3%
Percentage of long-stay residents who lose too much weight 6.9%
6.1%
0.8 pts worse
5.4%
1.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 11.3% · Q3 6.9% · Q4 6.1% · 4Q avg 6.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 10.3%
13.5%
3.2 pts better
19.6%
9.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 10.4% · Q3 7.7% · Q4 11.7% · 4Q avg 10.3%
Percentage of long-stay residents who received an antipsychotic medication 17.2%
14.8%
2.4 pts worse
16.7%
0.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 17.1% · Q3 20.5% · Q4 22.0% · 4Q avg 17.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.3%
0.2%
0.1 pts worse
0.1%
0.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3%
Percentage of long-stay residents whose ability to walk independently worsened 6.4%
15.1%
8.7 pts better
16.3%
9.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 7.0% · Q3 2.5% · Q4 5.0% · 4Q avg 6.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 9.9%
15.5%
5.6 pts better
14.9%
5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 12.7% · Q3 8.0% · Q4 9.5% · 4Q avg 9.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.4%
0.6%
0.2 pts better
1.0%
0.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.7%
1.4%
0.7 pts better
1.7%
1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.4% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 26.4%
20.8%
5.6 pts worse
19.8%
6.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 30.7% · Q3 16.9% · Q4 28.4% · 4Q avg 26.4%
Percentage of long-stay residents with pressure ulcers 9.5%
6.9%
2.6 pts worse
5.1%
4.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 10.7% · Q3 12.5% · Q4 7.0% · 4Q avg 9.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 76.2%
76.7%
0.5 pts worse
81.7%
5.5 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 72.0% · Q2 77.9% · Q3 77.4% · Q4 76.7% · 4Q avg 76.2%
Percentage of short-stay residents who had an outpatient emergency department visit 20.0%
9.7%
10.3 pts worse
12.0%
8 pts worse
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 22.9% · Expected 12.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 2.1%
1.2%
0.9 pts worse
1.6%
0.5 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.3% · Q3 0.0% · Q4 2.0% · 4Q avg 2.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 76.0%
78.8%
2.8 pts worse
79.7%
3.7 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 24.6%
20.6%
4 pts worse
23.9%
0.7 pts worse
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 29.5% · Expected 28.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-08-09 · Fire 2024-08-09

11 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)

12 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2023-03-24 · Fire 2023-03-24

5 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

15 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2021-04-14 · Fire 2021-04-14

5 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

7 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-08-09

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2024-09-26

E · Potential for more than minimal harm 2024-08-09

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2024-10-07

E · Potential for more than minimal harm 2024-08-09

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-10-07

E · Potential for more than minimal harm 2024-08-09

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-10-07

E · Potential for more than minimal harm 2024-08-09

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-07

E · Potential for more than minimal harm 2024-08-09

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-10-07

E · Potential for more than minimal harm 2024-08-09

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-10-07

E · Potential for more than minimal harm 2024-08-09

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-10-07

E · Potential for more than minimal harm 2024-08-09

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-09

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-10-07

C · Minimal harm 2024-08-09

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-10-07

C · Minimal harm 2024-08-09

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2024-10-07

E · Potential for more than minimal harm 2023-03-24

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2023-05-12

E · Potential for more than minimal harm 2023-03-24

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-05-12

E · Potential for more than minimal harm 2023-03-24

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2023-05-12

E · Potential for more than minimal harm 2023-03-24

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-05-12

E · Potential for more than minimal harm 2023-03-24

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2023-05-12

E · Potential for more than minimal harm 2023-03-24

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-05-12

E · Potential for more than minimal harm 2023-03-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-05-12

E · Potential for more than minimal harm 2023-03-24

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-05-12

E · Potential for more than minimal harm 2023-03-24

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2023-05-12

E · Potential for more than minimal harm 2023-03-24

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2023-05-12

E · Potential for more than minimal harm 2023-03-24

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-05-12

E · Potential for more than minimal harm 2023-03-24

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-05-12

D · Potential for more than minimal harm 2023-03-24

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-05-12

C · Minimal harm 2023-03-24

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2023-05-12

C · Minimal harm 2023-03-24

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2023-05-12

E · Potential for more than minimal harm 2021-04-14

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Not marked corrected

E · Potential for more than minimal harm 2021-04-14

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2021-06-08

E · Potential for more than minimal harm 2021-04-14

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2021-06-08

E · Potential for more than minimal harm 2021-04-14

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-06-08

E · Potential for more than minimal harm 2021-04-14

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2021-06-08

E · Potential for more than minimal harm 2021-04-14

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2021-06-08

D · Potential for more than minimal harm 2021-04-14

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2021-06-08

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-11-24

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2026-01-19

D · Potential for more than minimal harm 2025-11-24

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2026-01-19

D · Potential for more than minimal harm 2025-03-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-15

F · Potential for more than minimal harm 2024-08-09

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2024-10-07

E · Potential for more than minimal harm 2024-08-09

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-09

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-09

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-09

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-09

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-09

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-09

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2024-10-07

F · Potential for more than minimal harm 2023-03-24

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-05-12

E · Potential for more than minimal harm 2023-03-24

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2023-05-12

D · Potential for more than minimal harm 2023-03-24

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-05-12

D · Potential for more than minimal harm 2023-03-24

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-05-12

D · Potential for more than minimal harm 2023-03-24

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2023-05-12

D · Potential for more than minimal harm 2021-04-14

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2021-06-08

D · Potential for more than minimal harm 2021-04-14

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2021-06-08

D · Potential for more than minimal harm 2021-04-14

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2021-06-08

D · Potential for more than minimal harm 2021-04-14

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2021-06-08

D · Potential for more than minimal harm 2021-04-14

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2021-06-08

Penalties and ownership

What sits behind the stars

Ownership

Strauss, Jeremy

5% Or Greater Direct Ownership Interest · Individual

95% 15 facilities 2021-11-05
Strauss, Elliot

5% Or Greater Direct Ownership Interest · Individual

5% 1 facilities 2021-11-05
Balan, Belinda

Operational/Managerial Control · Individual

0% 1 facilities 2023-09-06
Stern, Samuel

Corporate Officer · Individual

0% 74 facilities 2021-11-05

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