Elderwood at Cheektowaga

Inspectors wroteBased on observations, interviews, and record reviews conducted during survey, the facility failed to ensure that each residents' environment remained as free of accidents as possible and each resident received supervision to prevent accidents for three (3) (Residents #30, #87, and #116) of nine (9) residents reviewed for accident hazards. Specifically, Resident #87 had frequent witnessed and unwitnessed falls from 12/03/2025, through 04/20/2026. The facility failed to assess, implement and evaluate the effectiveness of safety interventions. As a result of the repeated falls, Resident #87 suffered multiple injuries such as bruising, cuts and abrasions. The resident also suffered pain, a left wrist fracture and non-displaced acute fracture of the lateral humeral condyle (elbow); fractures of their left 11th and 12th ribs; [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the survey, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for four (4) (Unit One, Unit Two, Unit Three, and Unit Four) of four (4) resident units. Specifically, Resident #155's bathroom was damaged and dirty; bathing suites exhibited damaged floor and wall tiles, a damaged corner wall, damaged and loose grab bars, chipped paint, soiled shower curtains, dead flies, clogged drains, and a florescent light outage; and resident-use corridors had discolored and malodorous carpeting throughout the entire facility.

Inspectors wroteBased on interviews, observations, and record review conducted during the survey, facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to have sufficient nursing staff to provide nursing care to all residents in accordance with the facility assessment and to meet the needs of each resident. Residents #1, 3, 10, 30, 52, 69, 70, 90, 102, 117, 122, 151, 155, 156, and 167 were involved.

Inspectors wroteBased on observations, interviews, and record review conducted during the survey, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, observations of one (1) of one (1) kitchen revealed active wastewater discharge in the main kitchen's dishwashing area; two (2) of two (2) walk-in freezer units had an accumulation of ice on interior wall surfaces, floors, and ceilings, and one (1) of two (2) walk-in refrigeration units had an accumulation of water on the floor.

Inspectors wroteBased on interview and record review conducted during an extended Standard survey completed on 04/23/2026, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the administration did not ensure residents were free of accident hazards had adequate supervision and facility policies and protocols were consistently implemented and monitored for their effectiveness. This has the potential to affect all residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record review conducted during the survey, the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program effectively developed and implemented appropriate plans of action to correct identified quality deficiencies related to resident safety with the potential to cause serious harm to residents. Specifically, the facility failed to implement effective systems to maintain resident safety.

Inspectors wroteBased on observations, interviews, and record review conducted during the survey, the facility failed to establish smoking policies in accordance with applicable Federal, State, and local laws regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents. Specifically, one (1) of one (1) facility reviewed did not develop a smoking policy for residents who smoke and were not grandfathered in. This involved Resident #30 and #116.

Inspectors wroteBased on observations, interviews and record review conducted during the survey, 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 two (2) (Resident's #3 and #30) of five (5) residents reviewed for choices. Specifically, showers were not offered twice weekly as planned (Resident #3) and Resident #30 was not out of bed and in the dining room for all meals as planned as per their preference.

Inspectors wroteBased on observations, interview, and record review conducted during the survey, the facility failed to 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 (1) (Resident #102) of six (6) residents observed for activities of daily living care provided to dependent residents. Specifically, Resident #102 was observed on multiple occasions with greasy hair and there was no documented evidence they received their scheduled showers.

Inspectors wroteBased on interview and record review conducted during the survey, the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice and the comprehensive centered care plan for one (1) (Resident #162) of one (1) resident reviewed. Specifically, there was a lack of communication between staff when Resident #162 was admitted to the facility resulting in delayed admissions processes which included physician's orders, assessments and meeting the needs of the resident.

Inspectors wroteBased on observation, interview, and record review conducted during the survey, the facility failed to provide pain management 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 #69) of one (1) resident reviewed for pain management. Specifically, Resident #69 did not receive their pain medication in a timely manner on 04/17/2026.

Inspectors wroteBased on record review and interview conducted during the survey, the facility failed to ensure Certified Nurse Aide performance reviews were completed once every 12 months per year for three (3) (Certified Nurse Aides #3, #9, #10) of five (5) reviewed. Specifically, there was no evidence Certified Nurse Aides #3, #9, #10, who had worked for the facility more than 12 months had performance reviews completed at least once every 12 months.

Inspectors wroteBased on observation, interview and record review conducted during the survey, the facility failed to maintain drugs and biologicals labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary standards, and expiration date when applicable for one (1) of four (4) resident units reviewed for medication storage. Specifically, the facility failed to ensure the safe and secure storage of medications. The Unit four (4) South medication cart was not locked and under the direct view of authorized staff. The computer system on the cart had visible patient health information displayed in an area where residents, staff, and visitors had access. Resident #75 was involved. [...]

Inspectors wroteBased on observation, interviews and record review conducted during the survey, the facility failed to ensure each resident received food that accommodated resident allergies, intolerances, and preferences for one (1) (Resident #164) of one (1) resident reviewed. Specifically, Resident #164 received pork against their religious food preference.

Inspectors wroteBased on observations, interviews, and record review conducted during the survey, the facility failed to ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) (Resident #8 and Resident #70) of three (3) residents reviewed for Infection Prevention and Control. [...]

Inspectors wroteBased on interviews and record review conducted during the survey completed the facility failed to ensure certified nurse aides were provided the required hours of training and/or annual in-services to ensure safe delivery of care for two (2) (Certified Nurse Aides #2 and #9) of five (5) reviewed. Specifically, Certified Nurse Aides #2 and #9 did not receive 12 hours of nurse aide in-services and education in 2025.

Inspectors wroteBased on interviews and record review conducted during the survey, the facility failed to designate one (1) or more individuals as the Infection Preventionist responsible for the facility's Infection Prevention Control Practices. Specifically, the facility did not have a designated Infection Preventionist qualified with specialized education, training, experience, or certification on a part time or fulltime basis.

Inspectors wroteBased on interview and record review during the Standard survey completed on 04/23/2026, the facility failed to 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, three (3) employees (Certified Nursing Assistant #12, Activity Leader #1, and Housekeeping Aide #1) of 11 employees that were subject to the New York State Nurse Aide Registry Verification, were not reviewed through the New York State Nurse Aide Registry prior to their employment as required.

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 04/23/26, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2025 Fire Code of New York State, which requires that an interior space in a Nursing Home that contains a direct carbon monoxide source shall be provided with carbon monoxide detection if there are communicating openings between the spaces, and on-going preventative maintenance of carbon monoxide detectors. This affected four (4) (Unit 1, Unit 2, Unit 3, and Unit 4) of four (4) resident units and one (1) of one (1) Service corridor on two (2) (First floor and Second floor) of two (2) resident use floors.

Inspectors wroteBased on interview and record review the facility did not ensure infection control practices were maintained to include when the COVID -19 vaccine is available to the facility, each resident is offered the COVID -19 vaccine unless immunization is medically contraindicated or the resident has already been immunized. Before offering COVID-19 vaccine, each resident or the resident representative received education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine; the resident has the opportunity to accept or refuse the COVID-19 vaccine and change their decision and that the resident's medical record includes documentation that indicated if a resident did not receive the COVID-19 vaccine due to medical contraindications or refusal for one (1) of three (3) residents reviewed for infection control. [...]

Inspectors wroteBased on interview and record review conducted during the survey, the facility did not ensure that a resident has the right to refuse treatment for two (2) (Resident #1 and #2) of three (3) residents reviewed for immunizations. Specifically, Resident #1 and Resident #2's Representatives did not give consent to administer the COVID-19 and influenza vaccines, and the residents received them.

Inspectors wroteBased on interview and record review conducted during the survey, the facility did not maintain accurate medical record documentation for three (3) (Resident's #1, #2, and #3) of three (3) residents reviewed. Specifically, Residents #1, #2 and #3 were administered vaccinations by an outside pharmacist that were documented as being administered by facility nurses.

Inspectors wroteBased on observation, interview, and record review completed during a Complaint (2590368) investigation completed on 11/05/2025 the facility did not ensure that residents who had an indwelling Foley catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (1) (Resident #3) of three (3) residents reviewed for foley catheters. Specifically, Resident #3 had a history of urinary tract infections and staff did not keep the urine collection bag below the level of Resident #3's bladder while the resident was sitting in their wheel chair, was not wearing a urine collection leg bag (a drainage bag that is attached to the thigh) as care planned, and there was no medical provider orders for the indwelling catheter and/or care of it. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Abbreviated Survey (Complaint #NY00376392) the facility did not ensure the resident's right to be free from verbal/mental abuse for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Certified Nurse Aide #1 was witnessed yelling at Resident #1. The finding is: The policy and procedure titled Abuse Prevention, Identification, Investigation, Protection and Reporting revised 4/30/24 documented the facility will provide protection for the health, welfare and rights of each resident residing in the facility. [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 6/18/24, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and Director of Nursing (DON) for one (Resident #25) of five residents reviewed for drug regimen reviews. Specifically, the Consultant Pharmacist did not identify, or report medications prescribed and administered (antibiotic) for an excessive duration and did not identify and report inadequate indications for the continued use of that antibiotic. The finding is: The policy and procedure titled Medication Regiment Review by Pharmacy Consultant dated 12/2021 documented the pharmacy consultant will assess the medication regimen and review the medical chart of all residents monthly. [...]

Inspectors wroteBased on record review and interviews conducted during the Standard survey completed on 6/18/24, the facility did not ensure that the facility's infection and control program included antibiotic use protocols and a system to monitor antibiotic use for one (Resident #25) of one resident reviewed. Specifically, Resident #25 was receiving an antibiotic since 11/22/20. The use of the antibiotic was not monitored and tracked by the Infection Preventionist (IP)/Antibiotic Stewardship Program. The finding is: Review of the policy and procedure titled Antibiotic Stewardship Program dated 1/2018, documented that the antibiotic stewardship program will provide a framework to ensure that antimicrobials are used appropriately and prudently within the facility. The framework would be overseen by the Infection Prevention and Control Committee. [...]

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey completed [DATE], the facility did not ensure the system developed for advanced directives was implemented in a manner that was consistent with residents' wishes for one (Resident #8) of one resident reviewed for advanced directives. Specifically, Resident #8's Medical Orders for Life-Sustaining Treatment (MOLST) form and was not reviewed and renewed since [DATE]. The finding is: [...]

Inspectors wroteBased on interview, and record review conducted during a Complaint investigation (#NY00330303) during the Standard survey completed on 6/18/24, the facility did not ensure the residents representative was notified of the need to alter treatment or to commence a new form of treatment and when there was a change in room assignment for one (Resident #152) of two residents reviewed. Specifically, the resident and resident's responsible party were not notified of a room change on 11/30/23. Additionally, when Resident #152 tested positive for COVID-19 on 12/17/23, there was no evidence their responsible party was notified. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#NY00340373) during a Standard survey completed 6/18/24, the facility did not ensure residents have the right to personal privacy for one (Resident #41) of one resident reviewed. Specifically, staff did not provide privacy during personal care. The finding is: The policy and procedure dated 6/6/22 documented that each staff member will be personally responsible for ensuring that the rights of each resident are respected and not violated. Staff shall ensure that all residents are afforded their right to privacy in treatment and care for personal needs. The policy and procedure dated 8/1/2019 documented each resident has the right to be treated with dignity and respect. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 6/18/24, 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 (Unit 4) of two medication storage rooms observed. Specifically, the Unit 4 medication storage room refrigerator had three opened, undated and one opened, outdated multi-dose vials of Tubersol solution (medication injected just under the skin to test for tuberculosis). Additionally, the Unit 4 medication storage room cabinet had issues with expired over the counter medications. The finding is: [...]

Inspectors wroteBased on record review and interview conducted during a Complaint investigation (#NY00336714) during the Standard survey completed on 6/18/24, the facility did not obtain or provide radiology services to meet the needs of its residents for one (Resident #150) of one resident reviewed. Specifically, Resident #150 was ordered to have a lumbar (section of the spine) x-ray completed on 2/28/24 but did not have the x-ray completed until 3/4/24. Additionally, the order for x-rays obtained on 2/28/24 was not entered into Resident #150's electronic medical record. The finding is: [...]

Inspectors wroteBased on interview and record review conducted during a Complaint Investigation (#NY00328763) completed 2/8/24, the facility did not ensure that all alleged violations of abuse, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse, to the facility's Administrator and the State Survey Agency for one (Resident #1) of three resident reviewed. Specifically, Resident #1 reported an allegation of abuse/mistreatment to facility staff on 11/24/23 and it was not reported in the required timeframe to the Administrator and the New York State Department of Health. The finding is: [...]

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (Complaint #NY00328763) completed on 2/8/24, the facility did not ensure that all alleged violations of abuse, neglect or mistreatment were thoroughly investigated for one (Resident #1) of three residents reviewed. Specifically, there was no evidence that Resident #1's allegation of abuse/mistreatment on 11/24/23 was thoroughly investigated. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00322117) started completed 11/21/23, the facility did not ensure that services were provided to meet professional standards of quality care for one (Resident #1) of three residents reviewed. Specifically, medications were left unattended on Resident #1 bedside table and were not verified that they were taken as ordered. The finding is: The facility policy and procedure (P&P) titled Medications Administration Methods last modified 7/12/2022 documented a medication must never be left at bedside or be out of sight of the nurse administering the medication. The nurse must watch each resident take the medication, and ensure the medication is swallowed, unless the resident has an order for self-administration of medications. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed 9/27/22 through 10/3/22, the facility did not ensure that a resident, with an indwelling catheter (Foley - tube inserted into the bladder to drain urine), received the appropriate care and services to prevent urinary tract infections (UTIs) to the extent possible for two (Residents #106 and 120) of three residents reviewed for urinary catheters. Specifically, staff improperly handled the urinary catheter tubing and urinary collection bag while resident displayed symptoms of a UTI (Residents #106 and 120). In addition, Resident #120 had no leg bag in place when out of bed as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review completed during the Standard survey conducted 9/27/22 through 10/3/22, the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #88) of five residents reviewed for unnecessary medications. Specifically, a physician order to discontinue the antipsychotic medication Quetiapine Fumarate (Seroquel) was not implemented, which caused the resident to receive the medication without adequate indication for continued use. The finding is: [...]

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey started 9/27/22 and completed on 10/3/22 the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, two (Units one and two) of four resident units reviewed for food temperatures during meals had issues involving food items that were not served at safe and appetizing temperatures. Residents #1, #14, #63 and #73 were involved.