Elderwood at Amherst

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#2675690) during an Abbreviated survey completed on 12/04/2025, the facility did not ensure the resident's right to be free from physical and mental abuse for two (2) (Residents #1 and #2) of three (3) residents reviewed. Specifically, Certified Nurse Aide #1 attempted to redirect Resident #1, a wandering resident to a seated position. The physical handling during this process was observed as aggressive. Resident #1 lost their balance, fell to the floor, and sustained a small abrasion to their side. A physical struggle occurred after Resident #2 unplugged a power cord; Certified Nurse Aide #2 responded aggressively, moving the resident against a wall to recover the cord. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 4/18/25, the facility did not ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for two (2) (Resident #47 and Resident #52) of three (3) residents reviewed. Specifically, palm guards (shield/protectors/splint) use for contractures (loss of joint mobility) were not provided at all times as planned and recommended by Occupational Therapy. The policy and procedure titled Splint, Brace Care dated 5/23/18 documented the need for splint or brace use is assessed by a Licensed Therapist and recommendations would be issued for the type of device to be worn and the scheduled use. The program would be designated by the therapist and carried out by nursing. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard Survey completed on 4/18/2025, the facility did not ensure it was free of a medication error rate of five percent or greater for two (2) (Residents #31 and #44) of three (3) residents observed during medication administration. Specifically, there were two (2) errors for 25 observed medication opportunities resulting in a medication error rate of 8% (percent). Medications were not administered to Resident #31 and #44 in accordance with the physician's order before breakfast.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 4/18/25, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and include the expiration date when applicable for one (1) (Unit One) of two (2) medication storage rooms, and one (1) (Unit One/Cart 2) of three (3) medication carts observed. Specifically, Unit One's medication room contained multiple unopened, bottles of expired medications and Unit One's medication cart (Cart 2) contained an insulin pen that was not dated when opened. The finding is: The policy and procedure titled Medication Rooms on Nursing Units dated 7/30/24 documented medication rooms on the nursing units of the facility will be the areas where medications for residents are stored. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Abbreviated Survey (Complaint #NY00347516) the facility did not ensure they treated each resident with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #2) of three residents reviewed. Specifically, Resident #2 was treated by Certified Nurse Aide #1 in an undignified manner during care. Resident #2 told Certified Nurse Aide #1 they were hurting their arms by rushing them; Certified Nurse Aide #1 threw their clothes at them and stated, well then put them on yourself. The finding is: [...]

Inspectors wroteBased on record review and interviews conducted during an Extended Recertification survey started on [DATE] and completed on [DATE], the facility failed to initiate cardiopulmonary resuscitation (CPR) to an unresponsive resident who had a full code status and advance directives in place for one (Resident #79) of three residents reviewed. Specifically, on [DATE] Resident #79 was found unresponsive, without a pulse, respirations, or blood pressure. Facility staff failed to check the resident's code status, failed to initiate emergency response, failed to activate the 911 (emergency medical response) system, and failed to provide cardiopulmonary resuscitation (CPR) for the resident who was a full code. Resident #79 expired on [DATE]. [...]

Inspectors wroteBased on interview and record review during the Extended survey completed on 12/15/23, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified four (two Certified Nurse Aides, one Housekeeping Aide, and one Dining Service Associate) of six employees reviewed that worked in the facility and were subject to the New York State Nurse Aide Registry had been screened through the New York State Nurse Aide Registry prior to their first date worked at the facility.

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00301447) during an Extended Recertification survey completed on 12/15/23, the facility did not ensure the resident's right to be free from abuse for two (Residents #20 and 52) of five residents reviewed. Specifically, on 8/29/22 at 8:40 PM, Resident #52 wandered into Resident #20's room without staff knowledge and were found lying in Resident #20's bed, naked, and engaged in sexual intercourse. The finding is: [...]

Inspectors wroteBased on observation, interview and record review during the Standard survey conducted from 4/27/22 through 5/3/22, the facility did not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Three (Units 1, 2, and 3) of three resident units reviewed for dignity with dining had an issue involving meals served on disposable plates. This involved Resident #s 9, 17, 48 and 72. The finding is: The facility policy and procedure titled Dignity dated 8/1/19 documented each resident has the right to be treated with dignity and respect. Examples of treating residents with dignity and respect include but are not limited to: promoting resident independence and dignity while dining, such as avoiding daily use of disposable cutlery and dishware. 1. [...]

Inspectors wroteBased on interview and record review during the Standard survey conducted from 4/27/22 through 5/3/22, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries. Specifically, for one (Resident #125) of three residents reviewed for beneficiary protection notification, the facility did not provide the resident or responsible party (RP) with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN- a letter given to residents who are terminated from Medicare coverage and remain in the facility) at the termination of Medicare Part A benefits. The finding is: [...]

Inspectors wroteBased on observation, interview and record review during a Standard survey conducted from 4/27/22 through 5/3/22 the facility did not ensure that each resident who was unable to carry out activities of daily living (ADL) receives the necessary services to maintain grooming and personal hygiene for one (Resident #50) of four residents reviewed for ADL's. Specifically, Resident #50 had long jagged and dirty fingernails on both hands and thick coarse chin hair. The finding is: Review of the facility policy and procedure (P&P) titled ADL Assistance and Supervision dated 1/8/2018 documented the Unit Manager/designee will ensure that a plan of care for receiving ADL assistance and/or supervision is incorporated into the daily nursing care of each resident. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed from 4/27/22 through 5/3/22, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #121) of one resident reviewed for quality of care related to venous access devices. Specifically, there was no documented evidence of monitoring or care of the resident's accessed Mediport (needle inserted into the central venous access device). The finding is: The facility policy and procedure titled, Huber Needle Termination dated 8/26/19, documented needles being used for continuous intravenous (IV) therapy will be changed on a weekly basis unless otherwise specified in the attending physician's orders. [...]