Elderwood at Williamsville

Inspectors wroteBased on interviews and record review conducted during a survey, the facility failed to check the code status to an unresponsive resident who had a Do Not Resuscitate (DNR) Order with Advance Directives in place for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Resident #1 was found unresponsive on [DATE] at 2:09 PM, without a pulse, respirations, or blood pressure by Licensed Practical Nurse #1. Licensed Practical Nurse #1 failed to check code status of Resident #1 and initiated Cardiopulmonary Resuscitation (CPR). Based on interviews and record review it was determined the facility corrected the non-compliance as of [DATE] and was cited at Past Noncompliance.

Inspectors wroteBased on interview, and record review conducted during an Abbreviated survey (Complaint #NY00374712), the facility did not ensure that pharmaceutical services (including procedures that assure the accurate administering of all drugs) met the needs of each resident for one (Resident #1) of three residents reviewed. Specifically, the facility did not ensure nursing staff administered Resident #1's anticonvulsant medications within the allowed administration timeframe and/or that the medication was signed for at the time of administration. Additionally, the Medical Provider was not notified. The finding is: The policy titled Liberalized and Standardized Medication Administration Schedules dated 5/29/25 documented medications will be delivered in a manner that was least restrictive and intrusive while allowing for optimal therapeutic effect of medications. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint Investigation (#NY00370991) the facility failed to protect residents from sexual abuse for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Resident #1 was touched inappropriately by Resident #2. The policy and procedure titled Abuse Prevention, Identification, Investigation, Protection and Reporting dated 4/30/24 documented the facility will provide protection for the health, welfare and rights of each resident residing in the facility. The facility is responsible for prohibiting and preventing abuse of residents. The facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation. Actions will be taken to protect the resident from alleged perpetrators during an investigation. [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey and Complaint (#NY00348063) with an exit date of 1/21/2025, the facility did not ensure the resident's environment remained free from accident hazards over which the facility had control and provide adequate supervision and assistive devices to prevent accidents for one (1) (Resident #154) of three (3) residents reviewed for accidents. Specifically, on 7/13/2024 Resident #154 identified as severely cognitively impaired wandered off the 2nd floor Memory Care Unit (Unit 3) without staffs' knowledge, exited through the emergency stair-well door, which did not alarm, went down the stairs and exited the building through a second door to the outside. [...]

Inspectors wroteBased on interview, observation, and record review conducted during complaint investigations (#NY00359668, #NY00335735, #NY00349153, #NY00347833, #NY00350434) conducted during a Standard survey completed on 1/21/2025, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not having sufficient nurse staffing on a 24-hour basis to adequately care for residents' needs. Reference: F 688 Increase/Prevent Decrease in range of motion/mobility F 689 Free of Accident Hazards/Supervision/Devices The finding is but not limited to the following: [...]

Inspectors wroteBased on observation, interview and record during the Standard survey completed on 1/21/25, the facility did not ensure that food and drink was palatable, attractive and at a safe and appetizing temperature for five (Unit 1, Unit 2, Unit 3, Unit 4, and Unit 5) of five test trays. Specifically, food and beverages during meals were served at suboptimal temperatures, were not palatable and not attractive. Residents #53, #68, #94, #97, and #131 were involved.

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 1/21/25, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, issues included a dust laden ceiling, including devices on the ceiling, and a damaged wall. This affected one of one Main Kitchen.

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#NY00358228) completed during the Standard survey on 1/21/25, the facility did not ensure that each resident was treated 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 two (Resident #46 and #81) of eight residents reviewed for dignity. Residents #46 and #81 were treated in an undignified manner. Specifically, Certified Nurse Aide #10 pushed Resident #81 while they were in their wheelchair on the back two wheels lifting the front two wheels and pedals off the floor (in a wheelie type of motion). [...]

Inspectors wroteBased on interview, observation, and record review conducted during a Complaint investigation (#NY00335735) during a Standard survey completed on 1/21/2025, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #51) of two residents reviewed. Specifically, Resident #51 was not ambulated every day as recommended and planned. The finding is: The policy and procedure titled Ambulation Program dated 7/24/2018 documented that residents who need assistance with walking will be placed on a Unit Ambulation Program designed for improving, reinforcing, or maintaining the current status of a resident's ambulation. It also documented that the program is conducted by the unit nursing staff. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 1/21/25, 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 (Resident #53) of two residents reviewed. Specifically, Resident #53 had a recent history of urinary tract infection, and the foley drainage bag was not kept below the resident's bladder nor was the drainage tubing kept free of kinks. Additionally, the foley drainage bag and tubing was observed to be placed on the floor by staff. The finding is: The policy and procedure titled Catheter Daily Care (Indwelling) modified on 11/23/22 documented position of the drainage bags should be below the level of the bladder. Collection bags and tubing should not touch the floor. [...]

Inspectors wroteBased on interview and record review conducted during an Abbreviated survey (Complaint #NY00339512) completed on 4/23/24, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment 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 residents reviewed. Specifically, facility staff did not report an allegation of abuse/mistreatment of a resident to the Director of Nursing or the Administrator which resulted in the alleged abuse not getting reported to the appropriate officials including the New York State Department of Health as required. The finding is: [...]

Inspectors wroteBased on interview and record review conducted during an Abbreviated survey (Complaint #NY00339512) completed 4/23/24, the facility did not ensure that all alleged allegations of abuse, were thoroughly investigated for one (Resident #1) of three residents reviewed. Specifically, the facility did not complete a thorough investigation into an allegation of staff to resident physical abuse that included interviews or monitoring of other residents the accused staff member had cared for. The finding is: The policy and procedure titled Abuse Prevention, Identification, Investigation, Protection, and Reporting dated 3/25/24 documented all allegations of abuse and mistreatment will be investigated. [...]

Inspectors wroteBased on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00294465) completed on 1/26/24, 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 seven (Resident #3, #5, #6, #7, #8, #9, and #10) of seven residents reviewed for quality of care. Specifically, residents did not receive treatments as ordered by the physician. Issues involved pressure ulcer treatments (#3, 5, 6, 7, 8, 9, 10) and peripherally inserted central catheter (PICC) line care (#5, #9). The policy and procedure titled Medical Provider Notification Guidelines dated 2/13/20 documented the facility will utilize established guidelines as to when to notify the medical providers of urgent or non-urgent resident concerns. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey started on 12/14/22 and completed on 12/20/22, 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 one (Resident #17) of two residents reviewed for ADLs. Specifically, the CNA performed incomplete morning (AM) care, staff did not wash residents' hands which included long fingernails with brown debris under their nails and did not provide oral care or deodorant. In addition, there was lack of adequate hand hygiene and glove changes during care.

Inspectors wroteBased on observation, interview and record review conducted during a Standard Survey started 12/14/22 and completed 12/20/22, the facility did not ensure that a resident who enters the facility 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 one (Resident #70) of one resident reviewed for urinary catheters. Specifically, the Foley catheter was not secured to prevent kinking or tension, and a leg bag was not applied per the plan of care and the physician's orders for a resident with a history of urinary tract infections (UTIs). In addition, the Foley catheter and drainage bag were not secured properly, and the drainage bag fell to the floor during a mechanical lift transfer. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey started on 12/14/22, completed on 12/20/22, the facility did not ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with the physician's orders, and the comprehensive person-centered care plan for one (Resident #21) of one resident reviewed. Specifically, there was lack of physician orders and Registered Nurse (RN) assessment, for monitoring arm circumference, external length, and dressing changes of a PICC line catheter (peripherally inserted central catheter - a catheter that is inserted through a vein and advanced until the tip enters the central venous system). [...]

Inspectors wroteBased on observation, record review, and interview conducted during the Standard survey started 12/14/22 and completed 12/20/22, the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #85) of four residents reviewed for antipsychotic medications. Specifically, an order to decrease the antipsychotic medication Quetiapine Fumarate (Seroquel) was not implemented, which caused the resident to receive additional doses on 12/16/22 through 12/19/22. The finding is: Review of facility policy and procedure (P&P) titled Psychotropic Drugs last modified 7/6/18, documented residents prescribed psychotropic drugs will receive only those medications, in doses and for duration clinically indicated to treat the resident's assessed condition(s). [...]

Inspectors wroteBased on observation, record review, and interview conducted during a Standard survey started 12/14/22 and completed 12/20/22, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, three (Unit 1, Unit 3, and Unit 5) of four resident units reviewed for food temperatures during meals had issues involving food items that were not palatable and at safe and appetizing temperatures. Residents' #15, #85, #87 and #122 were involved.

Inspectors wroteBased on observation, record review and interview conducted during the Standard survey started 12/14/22 and completed 12/20/22, the facility did not provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks. Three (Resident #7, #14 and #85) of three residents reviewed for assistive devices were not provided inner lip plates for their meals.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey started 12/14/22 and completed 12/20/22, the facility did not store and distribute food in accordance with professional standards for food service safety. Specifically, there was unlabeled, undated, and outdated food in the refrigerators, the interior of the refrigerators and microwaves were soiled, and the refrigerators were missing thermometers on four (Unit 1, Unit 3, Unit 4, and Unit 5) of five resident unit nourishment rooms and one of one Activities refrigerator and Atrium freezer. Additionally, dietary staff with facial hair approximately one quarter of an inch long were observed in the Main Kitchen without beard nets.

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 9/23/20, the facility did not ensure that the resident's right to manage his or her financial affairs was maintained for one (Resident #74) of one resident reviewed for personal funds. Specifically, the resident requested a check of greater than $100.00 from his/ her facility personal funds account and did not receive the check within 3 business days. The finding is: The State Operations Manual effective November 28, 2017 documented residents requests for access to their funds should be honored by facility staff as soon as possible but no later than: the same day for amounts less than $100.00 ($50.00 for Medicaid residents); three banking days for amounts of $100.00 ($50.00 for Medicaid residents) or more. [...]

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 9/23/20, the facility did not ensure that all alleged violations involving abuse are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the appropriate officials (including the State Survey Agency) in accordance with State Law through established procedures. Specifically, for one (Resident #82) of one resident reviewed the facility did not report an incident of failure to follow the care plan resulting in Resident #82 falling out of bed (OOB) and sustaining a skin tear to the New York State Department of Health (NYSDOH) within the required timeframe. [...]