Elderwood at Hamburg

Based on observation, interview, and record review conducted during the survey, the facility did not ensure that services were provided to meet professional standards of quality care for one (1) (Resident #3) of six (6) residents reviewed. Specifically, Resident #3 did not receive all their evening medications as ordered by the medical provider, the nursing supervisor and medical provider were not notified of the omissions, and the Licensed Practical Nurse documented the medications were administered. The finding is: The policy titled Medications Administration Methods dated 01/25/2024, documented medication administration must be documented on the Medication Administration Record/Electronic Medication Administration Record immediately before going on to the next resident. The nurse will indicate if the medication was withheld or refused. Reasons are recorded on the Medication Administration Record/Electronic Medication Administration Record. The policy documented all problems related to medication are noted and later reported to unit manager/supervisor. The policy titled…

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 #2596250), the facility did not ensure that all alleged abuse violations were reported immediately but not later than 2-hours after the allegation was made to the Administrator of the facility and to the State Survey Agency for one (1) (Residents #1) of three (3) residents reviewed. Specifically, staff failed to report an allegation of physical abuse to the Administrator immediately which resulted in delayed reporting to the New York State Department of Health within the required time frames.The finding is:The policy titled Abuse Prevention, Identification, Protection and Reporting of Victims last revised on 4/30/2024 documented all facility staff were required to immediately report to the Administrator, Director of Nursing or designee when there was an observed act or suspicion of abuse, mistreatment or neglect. The facility Administrator or designee will report all alleged violations to, state agencies immediately, but no later than two (2) hours after the alleged abuse,…

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, record review, and interview conducted during the Standard survey completed on 6/5/25, the facility did not ensure residents had the right to choose activities, schedules, and health care consistent with their interests, assessments, and plan of care for one (1) (Resident #36) of five (5) residents reviewed for choices. Specifically, Resident #36 was not provided showers twice a week per their preference. The findings are: The policy and procedure titled Bath, Tub/Shower dated 8/7/2021 documented a shower or tub bath will be given once a week and/or as deemed necessary to all residents or per the resident's preference. The policy and procedure titled Resident Rights effective 2/24/2022 documented the facility shall ensure that all residents are afforded their right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and care for personal needs. The facility shall protect and promote the rights of each…

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 6/4/25, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (Resident #90) of five residents reviewed. Specifically, Resident #90 was not provided with timely incontinence care after they requested to be changed for AM care. The finding is: The policy titled Perineal, Incontinence Care dated 5/3/18 documented perineal care will be provided with morning and HS care (hour of sleep), and when residents are incontinent or cannot provide such care for themselves. Perineal care will be given to cleanse the genital area, to prevent infection and to eliminate odors. Nursing Assistants will perform perineal care for residents. The policy titled ADL (activities of daily living) Assistance and Supervision dated 1/8/18 documented the unit manager/designee will ensure that a plan of care for receiving activities of daily living assistance is incorporated into the…

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 the Standard survey completed on 6/4/25, the facility did not ensure that residents who had an indwelling foley catheter (tube inserted into the bladder to drain urine) received appropriate care and services to manage catheters for two (Resident #45 and Resident #96) of two residents reviewed. Specifically, infection control practices were not maintained (#45, #96) and staff did not utilize enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) when providing direct hands-on care (#45). The findings are: The policy and procedure titled Catheter; Daily Care (Indwelling) dated 11/23/22 documented position of the catheter bags should be below the level of bladder. Collection bags and tubing should not touch the floor. Barriers like dignity bags or basins may be necessary due to individual position needs. The policy and procedure titled Catheter, Emptying/Changing of Urinary Drainage Bag…

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 the Standard survey completed on 6/4/25, the facility did not ensure that pain management was provided to residents who require such services, consistent with standards of practices, the comprehensive person-centered care plan, and the resident's goals and preferences for one (1) (Resident #9) of one (1) resident reviewed for pain management. Specifically, there was a delay in addressing Resident #9's continued hip pain when non-opioid oral and topical analgesics (pain medications) were ineffective. The finding is: The policy titled Pain Management, dated 3/17/25, documented the to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences would be evaluated upon admission, readmission, through periodic assessments, and as needed. The interdisciplinary team was responsible for developing a pain management regimen. If the resident's pain was not controlled by…

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 10/3/23, the facility did not protect, promote, and treat each resident with respect and dignity and care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, four (Resident #8, #63, #71 and #80) of seven residents reviewed for dignity with dining were observed being fed by staff (Registered Nurse (RN) #2, Occupational Therapist, Registered (OTR), and Licensed Practical Nurse (LPN) #6) who were standing while providing meal assistance on multiple occasions. The findings are but not limited to the following: The policy and procedure titled Feeding Guidelines dated 3/12 documented, sit at residents' eye level while providing assistance with meals. 1.) Resident #8 has diagnoses including dementia, Alzheimer's disease, and diabetes mellitus. The Minimum Data Set (MDS - an assessment tool) dated…

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 the Standard survey completed on 10/03/23 the facility did not ensure that residents were free from physical restraints for the purposes of discipline or convenience, and that are not required to treat the resident's medical symptoms for one (Resident #83) of three residents reviewed. Specifically, Resident #83 was observed with a seat belt restraint, that was not ordered by the physician. The finding is: The policy & procedure (P&P) titled Physical Restraints Policy dated 5/24/2018 documented that a physical restraint will be defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, and which restricts freedom of movement or normal access to one's body. The P&P documented that physical restraints will only be used after all reasonable less restrictive alternatives have been considered and rejected for reasons related to the resident's well-being, and medical causes are ruled out. The use of a physical…

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 complaint investigations (Complaint #NY00322837) during the Standard survey completed on 10/3/23, the facility did not ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming, personal hygiene for one (Resident #47) of two residents reviewed. Specifically, the CNA (Certified Nurse Aide) lacked proper hand hygiene and glove changes during bowel incontinence care (Resident #47) and before touching items in the environment. The finding is: The policy and procedure (P&P) titled Perineal, Incontinent Care last modified 5/3/2018 documented perineal care will be provided when residents are incontinent or cannot provide such care for themselves. Assist resident onto bedpan, toilet, or commode chair or perform procedure directly in bed. In cleansing perineal areas of female resident, always cleanse from front perineal areas to rectum to prevent contamination of orifices. Discard gloves and wash hands thoroughly. Required for infection…

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 Complaint investigation (Complaint #NY00320987) during the Standard survey completed on 10/3/23, the facility did not ensure the resident environment was free of accident hazards as possible for two (Residents #60 & #94) of three residents reviewed for falls. Specifically, staff did not follow each resident's care plan which resulted in falls. The findings are: The policy and procedure (P&P) titled ADL (Activities of Daily Living) Assistance and Supervision last modified 1/4/2018, documented the Unit Manager/designee monitors the ADL assistance/supervision provided for residents throughout the shift and gives appropriate guidance and assistance to nursing staff. The Personal Care Profile/[NAME] and Care Plan are the documents to be referenced for the type of ADL assistance/supervision needed by a resident. The Nursing Assistant provides ADL assistance/supervision to assigned residents and assists other Nursing Assistants in giving ADL care as…

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 the Recertification Survey completed on 10/3/23, the facility did not ensure it is free of a medication error rate of five percent or greater for one (Resident #115) of 8 residents observed during medication administration. There were two errors for 27 observed medication opportunities resulting in a medication error rate of 7.41 % (percent). Specifically, medications were not administered to Resident #115 in accordance with the physician's order. The finding is: The policy and procedure titled Medication Administration Methods last modified 7/12/2022, documented the Medication Nurse must follow the five rights of administration (Right Drug, Right Dose, Right Time, Right Resident, Right Route). Medication may be administered one hour before or after the routine scheduled time, unless otherwise indicated. All problems related to medication administration are noted and later reported to Unit Manager/Supervisor. Resident #115 had diagnoses including hypokalemia (low potassium levels in the blood), history of falls, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a Standard survey completed on 10/13/21, the facility did not ensure that a resident who was unable to carry out activities of daily living receives the necessary services to maintain good grooming, and personal hygiene for one (Resident #54) of four residents reviewed for activities of daily living (ADLS). Specifically, Resident #54 was unshaven and had dark brown/ black debris beneath all their fingernails. The finding is: The facility policy and procedure (P&P) titled Hand and Nail Care dated 1/25/19 documented that residents will receive nail care for cleanliness and to prevent infection. Appropriately trained nursing assistants will provide nail care for all residents except those with diabetes mellitus or severe peripheral vascular disease. The facility P&P titled A.M. Care dated 4/10/2018 documented that morning (A.M.) care will be provided for all residents in preparation for breakfast and the daily routine. The procedure included 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.