Inspection Reports for
Elderwood at Amherst
4459 Bailey Ave, Amherst, NY, 14226
Back to Facility ProfileCitations (last 5 years)
Citations (over 5 years)
9.6 citations/year
Citations are regulatory findings recorded during state inspections.
88% worse than New York average
New York average: 5.1 citations/yearCitations per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Citations: 1
Date: Dec 4, 2025
Visit Reason
The inspection was conducted as a complaint investigation (#2675690) following allegations of physical and mental abuse of residents by certified nurse aides.
Complaint Details
Complaint investigation (#2675690) confirmed substantiated abuse involving two residents and two certified nurse aides. The investigation included video review, interviews, and record review. Both aides were suspended pending investigation and terminated after findings.
Findings
The facility failed to protect two residents from physical and mental abuse by two certified nurse aides, resulting in one resident falling and sustaining an abrasion and another resident being physically restrained and taunted. Both aides were suspended and subsequently terminated after the investigation confirmed abuse.
Citations (1)
Failure to protect residents from physical and mental abuse by staff, including aggressive handling causing a resident to fall and physical restraint and taunting of another resident.
Report Facts
Residents reviewed: 3
Residents affected: 2
Length of walking assistance: 150
Size of abrasion: 3.5
Size of abrasion width: 1.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Named in findings for physically abusive handling causing resident fall | |
| Certified Nurse Aide #2 | Named in findings for physically and mentally abusive actions including restraint and taunting | |
| Director of Nursing #1 | Director of Nursing | Identified as current for residents' care plans and completed investigative report |
| Nursing Supervisor Registered Nurse #1 | Nursing Supervisor Registered Nurse | Observed video footage and described abusive actions of aides |
| Unit Manager Licensed Practical Nurse #1 | Unit Manager Licensed Practical Nurse | Reviewed video and confirmed abusive actions of aides |
| Administrator | Administrator | Reviewed video footage and confirmed abuse, terminated involved aides |
| Nurse Practitioner #1 | Nurse Practitioner | Assessed residents post-incident and confirmed abuse |
| Inservice Educator Registered Nurse #2 | Inservice Educator Registered Nurse | Reviewed video and confirmed abuse, described expected staff behavior |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 8
Date: Apr 18, 2025
Visit Reason
Complaint Survey with 3 health and 5 life safety citations including medication errors and evacuation plan deficiencies, all corrected by June 12, 2025.
Findings
Complaint Survey with 3 health and 5 life safety citations including medication errors and evacuation plan deficiencies, all corrected by June 12, 2025.
Citations (8)
Free of medication error rts 5 prcnt or more
Increase/prevent decrease in rom/mobility
Label/store drugs and biologicals
Evacuation and relocation plan
Fire drills
Gas equipment - cylinder and container storag
Hazardous areas - enclosure
Sprinkler system - maintenance and testing
Inspection Report
Routine
Citations: 3
Date: Apr 18, 2025
Visit Reason
The inspection was a Standard survey conducted to assess compliance with regulatory requirements related to resident care, medication administration, and medication storage.
Findings
The facility was found deficient in providing appropriate care to residents with limited range of motion by not ensuring use of prescribed palm protectors for contractures. Additionally, the facility had a medication error rate of 8% due to late administration of medications before breakfast for two residents. The facility also failed to properly label and store medications, including expired medications in the medication room and an undated opened insulin pen on a medication cart.
Citations (3)
Failure to ensure residents with limited range of motion received appropriate treatment and services, specifically palm guards were not provided as recommended by Occupational Therapy for two residents.
Medication error rate of 8% due to medications not administered as ordered before breakfast for two residents.
Drugs and biologicals were not labeled in accordance with professional principles; expired medications were found in the medication storage room and an insulin pen was not dated when opened.
Report Facts
Medication error rate: 8
Number of residents reviewed for ROM deficiency: 3
Number of expired medication bottles observed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Administered medication late to Resident #31 | |
| Certified Nurse Aide #4 | Interviewed regarding care and use of palm protectors for Residents #47 and #52 | |
| Licensed Practical Nurse #6 | Interviewed regarding care and medication administration for Residents #44 and #52 | |
| Assistant Director of Rehabilitation | Interviewed regarding therapy recommendations for Residents #47 and #52 | |
| Director of Nursing | Interviewed regarding responsibility for ensuring care plans and medication administration compliance | |
| Registered Nurse Supervisor #1 | Interviewed regarding responsibility for checking medication storage room for expired medications | |
| Licensed Practical Nurse #3 | Interviewed regarding undated insulin pen on medication cart | |
| Medical Director | Interviewed regarding medication administration expectations | |
| Pharmacy Consultant | Interviewed regarding medication storage and labeling practices |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 2
Date: Jan 16, 2025
Visit Reason
Complaint Survey with 2 health citations related to administration and resident rights, both corrected by March 12, 2025.
Findings
Complaint Survey with 2 health citations related to administration and resident rights, both corrected by March 12, 2025.
Citations (2)
Organization and administration
Resident rights/exercise of rights
Inspection Report
Capacity: 60
Citations: 1
Date: Apr 8, 2024
Visit Reason
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Findings
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 12
Date: Dec 15, 2023
Visit Reason
Complaint Survey with multiple health and life safety citations including a Level 4 immediate jeopardy for CPR and various Level 2 deficiencies, all corrected by February 1, 2024.
Findings
Complaint Survey with multiple health and life safety citations including a Level 4 immediate jeopardy for CPR and various Level 2 deficiencies, all corrected by February 1, 2024.
Citations (12)
Cardio-pulmonary resuscitation (cpr)
Criminal history record check process
Develop/implement abuse/neglect policies
Free from abuse and neglect
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Elevators
Evacuation and relocation plan
Fire alarm system - testing and maintenance
Maintenance, inspection & testing - doors
Sprinkler system - maintenance and testing
Portable space heaters
Inspection Report
Capacity: 60
Citations: 1
Date: Dec 5, 2022
Visit Reason
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Findings
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: Nov 28, 2022
Visit Reason
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Findings
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: Nov 21, 2022
Visit Reason
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Findings
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: Nov 15, 2022
Visit Reason
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Findings
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: May 16, 2022
Visit Reason
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Findings
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Routine
Citations: 4
Date: May 3, 2022
Visit Reason
The inspection was conducted as a Standard survey from 4/27/22 through 5/3/22 to assess compliance with regulatory requirements related to resident dignity, beneficiary notification, activities of daily living assistance, and quality of care.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity by using disposable plates for meals, failure to provide appropriate Medicare beneficiary notices, inadequate assistance with activities of daily living such as grooming and nail care, and failure to properly monitor and care for a resident's accessed Mediport.
Citations (4)
Facility did not promote resident dignity by serving meals on disposable plates, causing resident dissatisfaction and difficulty eating.
Facility failed to provide appropriate liability and appeal notices to Medicare beneficiaries, specifically a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) at termination of Medicare Part A benefits for Resident #125.
Facility did not ensure Resident #50 received necessary assistance with grooming and personal hygiene, including long jagged fingernails and thick coarse chin hair.
Facility did not ensure residents received treatment and care according to orders and care plans, specifically no documented monitoring or care of Resident #121's accessed Mediport.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medicare Part A days used: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Discussed use of disposable plates and staffing issues related to meal service | |
| Registered Dietician | RD | Discussed use of paper products and resident complaints |
| Administrator | Discussed use of disposable products during COVID-19 and resident complaints | |
| Director of Nursing | DON | Discussed facility dignity policy and nail care/shaving practices |
| Certified Nurse Aide #2 | CNA | Described responsibilities for nail care and grooming |
| Licensed Practical Nurse #1 | LPN | Commented on dignity issues related to facial hair and nail care |
| Registered Nurse #3 | RN Unit Manager | Discussed nail care needs for Resident #50 |
| Registered Nurse #2 | RN | Discussed lack of knowledge and care for Resident #121's Mediport |
| Registered Nurse Unit Manager #1 | RN UM | Discussed Mediport care and admission assessment |
| Medical Director | Discussed policy for Mediport care and monitoring |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 4
Date: May 3, 2022
Visit Reason
Complaint Survey with multiple Level 2 citations related to ADL care, Medicaid/Medicare notices, quality of care, and resident rights; all corrected by June 27, 2022.
Findings
Complaint Survey with multiple Level 2 citations related to ADL care, Medicaid/Medicare notices, quality of care, and resident rights; all corrected by June 27, 2022.
Citations (4)
ADL care provided for dependent residents
Medicaid/medicare coverage/liability notice
Quality of care
Resident rights/exercise of rights
Inspection Report
Capacity: 60
Citations: 1
Date: Jan 31, 2022
Visit Reason
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Findings
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: Jan 24, 2022
Visit Reason
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Findings
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: Jan 17, 2022
Visit Reason
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Findings
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: Jan 10, 2022
Visit Reason
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Findings
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: Nov 29, 2021
Visit Reason
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Findings
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: Nov 22, 2021
Visit Reason
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Findings
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: Nov 15, 2021
Visit Reason
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Findings
Covid-19 Survey with a Level 2 citation for reporting to national health safety network; not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: Oct 27, 2021
Visit Reason
Covid-19 Survey with a Level 2 citation for Covid-19 testing of residents and staff; corrected by December 23, 2021.
Findings
Covid-19 Survey with a Level 2 citation for Covid-19 testing of residents and staff; corrected by December 23, 2021.
Citations (1)
Covid-19 testing-residents & staff
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