Elderwood at Lockport

Inspectors wroteBased on interviews and record reviews conducted during survey, the facility failed to ensure that the residents' environment remained as free of accidents as possible, and that each resident receives adequate supervision and assistance devices to prevent accidents for one (1) (Resident #1) of three (3) residents reviewed for accidents. Specifically, on 12/24/2025, the facility failed to use two (2)-person bed mobility assistance, from lying to sitting on the edge of the bed, resulting in Resident #1 falling to the floor, sustaining a left hip fracture requiring an open reduction internal fixation (ORIF-surgical procedure to realign and secure broken bones with metal fasteners). This resulted in actual harm to Resident #1 that is not Immediate Jeopardy.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 5/2/25, 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 (1) (Resident #6) of two (2) residents reviewed. Specifically, Resident #6 had a moderate amount of unwanted facial hair on their upper lip, chin, and neck. The finding is: The policy titled A.M. Care, dated 4/10/2018, documented AM (morning)care will be provided for all residents in preparation for breakfast and the daily routine. Part of AM care included assisting with grooming needs: shave or clip facial hair. The policy titled Shaving a Female Resident, dated 5/8/2018, documented a nursing assistant will shave the face of a female resident, as needed, to remove extraneous facial hair. [...]

Inspectors wroteBased on interview, observation, and record review conducted during a Standard survey completed on 5/2/25, the facility did not ensure that 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 one (1) (Resident #54) of four (4) residents observed for infection prevention and control during care. Specifically, staff did not wear personal protective equipment including gowns while providing incontinent care for Resident #54 who had ESBLs (extended spectrum beta-lactamase-an infection caused by antibiotic resistant bacterial enzymes) in their urine. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during Complaint investigations (#NY00309961, #NY00316113) during the Standard survey completed on 6/6/23, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three (East, West, North Units) of three resident care units. Specifically, the facility did not have adequate nursing staff based on the facility's established minimum number of staff for each unit and each shift. There was lack of answering resident call lights timely and providing toileting/incontinence care as planned. Resident's beds were not made, and residents didn't receive their medication on the East Unit the evening of 6/4/23. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a Standard survey completed on 6/6/23, the facility did not ensure each resident was treated with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #66) of two residents reviewed. Specifically, the facility did not ensure Resident #1 was treated with respect and dignity by a Certified Nurse Aide (CNA) while providing morning care. The finding is: The policy and procedure (P&P) titled Dignity dated 8/1/19, documented each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff must focus on assisting the resident in maintaining his or her self-esteem and self-worth. 1. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (NY00316113) during a Standard survey completed on 6/6/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for three (Residents #39, #74 and #101) of six residents reviewed for ADL's. Specifically, Residents #39 and #74 did not receive assistance with toileting needs as per their plans of care and Resident #101 did not receive assistance with their preferred number of showers per week as per their plan of care.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 6/6/23, the facility did not maintain 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 infection for two (Residents #35 and 66) of four residents reviewed for infection control practices during personal care. Specifically, staff did not perform adequate hand hygiene while providing fecal incontinence care (Resident #66) and pressure sore treatment (Resident #35). Additionally, when emptying a urinary drainage collection bag, staff did not use a barrier on the floor or alcohol to wipe the collection bag drain tube (Resident #35).

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 6/6/23, the facility did not post, on a daily basis, the following information: resident census. Specifically, the posted staffing reports did not include the facility census number as required. The finding is: The policy and procedure (P&P) titled Posting of Daily Resident Care Staffing (BIPA) dated 4/12/18 documented SNF (skilled nursing facility) staffing will be posted daily at the beginning of each shift. Other posted data included resident census. During observation on 5/31/23 at 9:05 AM, the DOH Staffing Report was posted in the lobby near the door to the administration offices. The posted report documented a census of 0 which did not reflect the current facility census. Review of the Midnight Census Report dated 5/30/23, documented the current resident census was 103. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard Survey completed on 7/30/21 the facility did not follow the prepared menus. One of one prepared lunch meal did not provide the residents receiving mechanically altered diets the same food item that was posted on the menus for that day. Specifically, on 7/28/21 puree and ground consistencies received ground pork with gravy instead of the Polish sausage which was listed on the posted menu. This affected the following residents (Resident #4, 5, 7, 21, 29, 40, 51, 60, 61, 69, 71, 86, 349, 352, and 353). The finding is: Review of the policy and procedure titled Diet Types and Menu Requirements date last modified 10/30/2018 revealed daily menus and menu cycles used at this facility will be planned to meet the nutritional and personal needs of residents. [...]

Inspectors wroteBased on observation, record review, and interview conducted during the Standard survey completed on 7/30/21, the facility did not establish and maintain 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 (Resident #s 43 and 60) of three residents reviewed for indwelling urinary catheters (Foley, tube inserted into the bladder used to drain urine). Specifically, proper infection control practices were not maintained. Residents #43 and #60's Foley catheter drainage bag (bag for collecting urine from the urinary drainage tube) and tubing were observed directly on the floor without a barrier.