Deficiencies (last 5 years)
Deficiencies (over 5 years)
10.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
108% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
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.
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.
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.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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. | Level of Harm - Minimal harm or potential for actual harm |
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
Deficiencies: 8
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.
Deficiencies (8)
| Description | Severity |
|---|---|
| Free of medication error rts 5 prcnt or more | Level 2 |
| Increase/prevent decrease in rom/mobility | Level 2 |
| Label/store drugs and biologicals | Level 2 |
| Evacuation and relocation plan | Level 2 |
| Fire drills | Level 2 |
| Gas equipment - cylinder and container storag | Level 2 |
| Hazardous areas - enclosure | Level 2 |
| Sprinkler system - maintenance and testing | Level 2 |
Inspection Report
Routine
Deficiencies: 3
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.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| 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. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate of 8% due to medications not administered as ordered before breakfast for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| 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. | Level of Harm - Minimal harm or potential for actual harm |
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
Deficiencies: 1
Jan 16, 2025
Visit Reason
The inspection was conducted as an Abbreviated Survey triggered by Complaint #NY00347516 regarding concerns about the treatment of Resident #2 by a Certified Nurse Aide.
Findings
The facility failed to ensure Resident #2 was treated with respect and dignity, as Certified Nurse Aide #1 treated the resident in an undignified manner by rushing care and throwing the resident's clothes at them. The aide was terminated for unsatisfactory care, resident abuse, and insubordination. Resident #2 felt undignified but not physically abused and felt safe in the facility.
Complaint Details
The complaint investigation found that Certified Nurse Aide #1 treated Resident #2 in an undignified manner by rushing care and throwing clothes at the resident. The aide was terminated for unsatisfactory care, resident abuse, and insubordination. Resident #2 reported feeling bad about needing help but did not feel physically abused. The facility responded promptly and the aide was no longer present.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Dates: Jul 8, 2024
Dates: May 22, 2024
Dates: Jan 15, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Named in undignified treatment of Resident #2 and terminated for unsatisfactory care and resident abuse |
| Director of Nursing | Director of Nursing / Acting Administrator | Conducted investigation and interviews, confirmed termination of Certified Nurse Aide #1 |
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed and stated the incident described was undignified and inappropriate |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed and stated Certified Nurse Aide #1 was not patient and got frustrated easily |
| Registered Nurse #1 | Registered Nurse | Interviewed and stated it would be undignified to toss resident's clothing and tell them to dress themselves |
| Acting Administrator | Acting Administrator (previous Director of Nursing) | Interviewed and confirmed Certified Nurse Aide #1 did not treat Resident #2 with dignity and respect |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
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.
Deficiencies (2)
| Description | Severity |
|---|---|
| Organization and administration | Level 0 |
| Resident rights/exercise of rights | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
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.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #NY00301447) triggered by an incident where Resident #52 was found in Resident #20's room engaged in sexual intercourse without staff knowledge.
Findings
The facility failed to ensure the residents' right to be free from abuse, specifically sexual abuse, involving two residents with severe cognitive impairment. The investigation found that Resident #52 entered Resident #20's room multiple times and was found engaged in sexual activity with Resident #20. Neither resident had capacity to consent, and the incident was considered sexual abuse with minimal harm and no physical injury noted.
Complaint Details
Complaint investigation #NY00301447. The complaint was substantiated as the facility did not ensure the residents' right to be free from sexual abuse. Both residents lacked capacity to consent. The incident was considered sexual abuse with minimal harm and no physical injury. Staff interviews and camera footage confirmed the timeline and circumstances of the incident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect residents from sexual abuse, specifically allowing Resident #52 to enter Resident #20's room and engage in sexual activity without staff knowledge or intervention. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Date of incident: Aug 29, 2022
Number of residents reviewed: 5
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Witnessed the residents engaged in sexual activity and reported the incident | |
| Registered Nurse #3 | Registered Nurse | Assessed Resident #52 after the incident and confirmed no injuries |
| Registered Nurse Supervisor #4 | Registered Nurse Supervisor | Reported the incident and confirmed the residents lacked capacity to consent |
| Director of Nursing | Director of Nursing | Acknowledged the incident as sexual abuse and confirmed residents' rights were not maintained |
| Attending Physician #2 | Attending Physician | Examined residents after the incident and found no trauma |
| Psychiatrist Consultant | Psychiatrist Consultant | Confirmed residents lacked capacity to consent and that the incident could cause harm |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 12
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.
Deficiencies (12)
| Description | Severity |
|---|---|
| Cardio-pulmonary resuscitation (cpr) | Level 4 |
| Criminal history record check process | Level 0 |
| Develop/implement abuse/neglect policies | Level 2 |
| Free from abuse and neglect | Level 2 |
| Electrical equipment - testing and maintenanc | Level 2 |
| Electrical systems - essential electric syste | Level 2 |
| Elevators | Level 2 |
| Evacuation and relocation plan | Level 2 |
| Fire alarm system - testing and maintenance | Level 2 |
| Maintenance, inspection & testing - doors | Level 2 |
| Sprinkler system - maintenance and testing | Level 2 |
| Portable space heaters | Level 2 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 15, 2023
Visit Reason
The inspection was conducted as a Complaint investigation related to allegations of abuse and failure to protect residents' rights at Elderwood at Amherst nursing home.
Findings
The facility failed to ensure residents' rights to be free from abuse, specifically sexual abuse involving two residents with severe cognitive impairment. Additionally, the facility failed to implement proper employee screening through the Nurse Aide Registry and failed to initiate CPR for a full code resident found unresponsive, resulting in immediate jeopardy. Several staff interviews and record reviews confirmed these deficiencies.
Complaint Details
The complaint investigation (Complaint #NY00301447) was triggered by an incident on 8/29/22 where Resident #52 wandered into Resident #20's room and engaged in sexual intercourse without staff knowledge. Both residents had severe cognitive impairment and lacked capacity to consent. The investigation confirmed the incident and found failures in abuse prevention and monitoring.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to protect residents from sexual abuse involving two residents with severe cognitive impairment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement written policies and procedures for screening employees through the New York State Nurse Aide Registry prior to hire. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide basic life support including CPR to a full code resident found unresponsive, resulting in immediate jeopardy. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents reviewed: 5
Residents affected: 2
Employees not screened: 4
Full code residents: 33
Licensed staff educated on Code Blue: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Certified Nurse Aide | Witnessed the sexual abuse incident and reported it |
| Registered Nurse #3 | Registered Nurse | Assessed Resident #52 after the sexual abuse incident and confirmed no injuries |
| Registered Nurse Supervisor #4 | Registered Nurse Supervisor | Reported observations and contacted Director of Nursing regarding the sexual abuse incident |
| Director of Nursing | Director of Nursing | Acknowledged the sexual abuse incident and failure to maintain resident rights |
| Attending Physician #2 | Attending Physician | Examined residents after the sexual abuse incident and confirmed no trauma |
| Psychiatrist Consultant | Psychiatrist Consultant | Confirmed residents lacked capacity to consent to sexual contact |
| Employee A | Dining Service Associate | Worked without Nurse Aide Registry screening documentation |
| Employee B | Housekeeping Aide | Worked without Nurse Aide Registry screening documentation |
| Employee C | Certified Nurse Aide | Registry checked after working eight shifts without prior screening |
| Employee D | Certified Nurse Aide | Registry checked after working three shifts without prior screening |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Found Resident #79 unresponsive but did not initiate CPR or emergency response |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Pronounced Resident #79 expired without checking code status or initiating CPR |
| Memory Care Program Specialist #1 | Memory Care Program Specialist | Noticed Resident #79 unresponsive and notified nurse but did not initiate CPR |
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Provided morning care to Resident #79 shortly before resident was found unresponsive |
| Attending Physician #1 | Medical Director | Reviewed Resident #79's advance directives and stated CPR should have been initiated |
Inspection Report
Capacity: 60
Deficiencies: 1
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.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
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.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
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.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
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.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
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.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Routine
Deficiencies: 4
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.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility did not promote resident dignity by serving meals on disposable plates, causing resident dissatisfaction and difficulty eating. | Level of Harm - Minimal harm or potential for actual harm |
| 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. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure Resident #50 received necessary assistance with grooming and personal hygiene, including long jagged fingernails and thick coarse chin hair. | Level of Harm - Minimal harm or potential for actual harm |
| 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. | Level of Harm - Minimal harm or potential for actual harm |
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
Deficiencies: 4
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.
Deficiencies (4)
| Description | Severity |
|---|---|
| ADL care provided for dependent residents | Level 2 |
| Medicaid/medicare coverage/liability notice | Level 2 |
| Quality of care | Level 2 |
| Resident rights/exercise of rights | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
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.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
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.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
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.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
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.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
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.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
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.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
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.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
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.
Deficiencies (1)
| Description | Severity |
|---|---|
| Covid-19 testing-residents & staff | Level 2 |
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