Elderwood at Hamburg

Inspectors wroteBased on interview and record review conducted during the survey, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for two (2) (Resident's #1 and #2) of ten (10) residents reviewed for accidents. Specifically, facility staff failed to implement safety measures during resident repositioning. Residents were not provided with the assistance of two (2) staff members during bed mobility as planned and the bed locking systems were unlocked. Resident #1 fell from the bed sustaining a right elbow injury later identified as a fracture (broken bone) and Resident #2 fell from bed and sustained a fracture of their left middle finger and multiple lacerations (cut that goes through more than one (1) layer of skin caused by trauma) to their head, face and arm. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, record review conducted during a Standard Survey completed on 10/3/23, the facility did ensure the Nurse Staffing information and data requirements were posted daily and the data was maintained for 18 months. Specifically, the facility did not keep the staffing data for 18 months and the facility did not update and post the daily Nurse Staffing information on 9/30/23, 10/1/23 and 10/2/23. The finding is: The policy and procedure(P&P) titled, Posting of Daily Resident Care Staffing (BIPA) dated 4/12/2018, it documented that Skilled Nursing Facilities (SNFs), and Nursing Facilities (NFs) staffing will be posted at the beginning of each shift the facility specific shift schedule for a 24-hour period licensed and unlicensed personnel who provide direct care to residents. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 10/13/21, the facility did not ensure that each resident receives and the facility provides food prepared by methods that conserve nutritive value, flavor and appearance and food that is palatable. Specifically, one (kitchen) of one kitchen reviewed for pureed food preparation had issues involving pureed food items that were not palatable or appetizing. The finding is: The policy and procedure (P&P) titled Level 1 Diet (pureed) dated 11/09 documented this diet meets recommended dietary allowances for all residents consists of pureed, homogenous (smooth) and cohesive (adhered together) foods. Foods should be pudding-like and no coarse textures. The recipe titled Pureed [NAME] Beans dated 2/11/19 documented Ingredients - green beans and water. [...]