Inspection Reports for
Elderwood at Cheektowaga
225 Bennett Road, Cheektowaga, NY, 14227
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
84% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding the care of residents with indwelling Foley catheters, specifically focusing on Resident #3's catheter care and related medical orders.
Complaint Details
The complaint investigation (2590368) focused on Resident #3's Foley catheter care. It was substantiated that the facility failed to provide appropriate catheter care, including improper drainage bag placement, lack of leg bag use, and missing provider orders for catheter management.
Findings
The facility failed to ensure appropriate care for Resident #3 with an indwelling Foley catheter, including improper placement of the drainage bag above bladder level, lack of a urinary leg bag as care planned, and absence of medical provider orders for catheter care. The resident's comprehensive care plan was not updated to reflect current urinary status and catheter needs.
Deficiencies (1)
F 0690: The facility did not provide appropriate care for residents with indwelling Foley catheters. Resident #3's catheter drainage bag was improperly positioned above bladder level, the resident was not wearing a urinary leg bag as care planned, and there were no medical provider orders for catheter care. The comprehensive care plan was not updated to reflect the resident's current urinary status.
Report Facts
Residents reviewed for Foley catheters: 3
Residents affected: Few residents affected as stated in the report
Date of complaint investigation: Investigation completed on 11/05/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Interviewed regarding catheter care and drainage bag placement for Resident #3 | |
| Registered Nurse #1 | Unit Manager | Interviewed about responsibility for updating care plans and catheter care orders |
| Registered Nurse #2 | Nursing Supervisor | Interviewed about admission assessments, provider orders, and care plan updates for Resident #3 |
| Physician Assistant #1 | Provided timeline and medical context for Resident #3's catheter placement and care | |
| Certified Nurse Aide #2 | Interviewed about care provided to Resident #3 and catheter leg bag use | |
| Certified Nurse Aide #3 | Interviewed about catheter drainage bag placement on Resident #3's wheelchair | |
| Registered Nurse #3 | Interviewed about proper Foley drainage bag placement and care plan accuracy | |
| Director of Nursing | Interviewed about catheter care policies, care plan accuracy, and provider orders |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 2, 2025
Visit Reason
The abbreviated survey was conducted in response to Complaint #NY00376392 alleging verbal/mental abuse of a resident by a Certified Nurse Aide.
Complaint Details
Complaint #NY00376392 was substantiated with reasonable cause to believe that verbal/mental abuse occurred to Resident #1 by Certified Nurse Aide #1 on 3/28/25 at 5:40 AM. The facility investigation confirmed the abuse and the employee was terminated.
Findings
The facility was found to have failed to protect a resident from verbal/mental abuse by a Certified Nurse Aide who was witnessed yelling at the resident. The abuse was substantiated and the Certified Nurse Aide was terminated.
Deficiencies (1)
10 NYCRR 415.4 (b)(1)(i) - The facility failed to protect Resident #1 from verbal and mental abuse by Certified Nurse Aide #1 who yelled at the resident and made disrespectful comments. The abuse was verified by investigation and witness statements.
Report Facts
Residents reviewed: 3
Date of abuse incident: Mar 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Named in verbal abuse finding and terminated | |
| Director of Nursing | Completed Nursing Home Investigative Report | |
| Licensed Practical Nurse #1 | Interviewed regarding abuse allegation | |
| Registered Nurse #1 Unit Manager | Reported allegation to Director of Nursing | |
| Social Worker #1 | Interviewed regarding abuse and facility culture | |
| Administrator | Interviewed regarding abuse and facility response |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: May 2, 2025
Visit Reason
One isolated Level 2 deficiency for free from abuse and neglect, corrected as of July 11, 2025.
Findings
One isolated Level 2 deficiency for free from abuse and neglect, corrected as of July 11, 2025.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on allegations regarding failure to notify residents' representatives of treatment or room changes, lack of privacy during personal care, and failure to provide timely radiology services.
Complaint Details
The complaint investigations (#NY00330303, #NY00340373, #NY00336714) substantiated failures in notification of resident changes, privacy violations during care, and delays in radiology services.
Findings
The facility failed to notify Resident #152 and their representative of a room change and COVID-19 positive status. Staff did not provide privacy during personal care for Resident #41. Resident #150 experienced delayed lumbar spine x-ray and incomplete documentation of x-ray orders.
Deficiencies (3)
F 0580: The facility did not notify Resident #152 or their responsible party of a room change on 11/30/23 or of a positive COVID-19 test on 12/17/23 as required by policy.
F 0583: Staff failed to provide privacy during personal care for Resident #41, leaving the resident exposed and visible to the hallway.
F 0776: Resident #150 did not receive a lumbar spine x-ray ordered on 2/28/24 until 3/4/24, and the order was not entered into the electronic medical record, causing a delay in treatment.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Involved in ordering and documenting x-rays for Resident #150 |
| Nurse Practitioner #1 | Nurse Practitioner | Ordered x-rays for Resident #150 and communicated with nursing staff |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Did not provide privacy during Resident #41's personal care |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Commented on privacy violation during Resident #41's care |
| Director of Nursing | Director of Nursing | Provided statements on notification and privacy expectations |
| Social Worker #1 | Social Worker | Responsible for notification process of room changes |
| Unit Manager | Unit Manager | Responsible for notification of room changes and family updates |
| Medical Doctor | Medical Doctor | Commented on expectations for x-ray orders and treatment |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jun 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on allegations regarding failure to honor residents' advanced directives, failure to notify residents and their representatives of changes in treatment or room assignments, failure to maintain resident privacy during care, improper medication regimen review, improper medication storage and labeling, delayed and incomplete radiology services, and inadequate antibiotic stewardship monitoring.
Complaint Details
The complaint investigations included issues with honoring advanced directives, notification failures regarding room changes and COVID-19 status, privacy violations during care, medication regimen review failures, medication storage and labeling issues, delayed and incomplete x-ray services, and inadequate antibiotic stewardship monitoring.
Findings
The facility was found deficient in multiple areas including failure to review and renew Medical Orders for Life Sustaining Treatment (MOLST) for a resident, failure to notify residents and their representatives of room changes and COVID-19 status, failure to maintain resident privacy during personal care, failure of the pharmacist to report medication irregularities, improper labeling and storage of medications, delay in obtaining ordered x-rays, and failure to monitor and track long-term antibiotic use.
Deficiencies (7)
10 NYCRR 400.21 (e)(1) - The facility did not ensure the system for advanced directives was implemented consistent with residents' wishes; Resident #8's MOLST form was not reviewed and renewed as required.
10NYCRR 415.3(d)(2)(ii)(a) and (c) - The facility failed to notify Resident #152 and their responsible party of a room change and COVID-19 positive status.
10 NYCRR 415.3(e)(1)(i) - Staff did not provide privacy during personal care for Resident #41, leaving the resident exposed and uncovered.
10 NYCRR 415.18(c)(2) - The Consultant Pharmacist did not identify or report irregularities related to prolonged antibiotic use for Resident #25.
10 NYCRR 415.18 (e)(4) - The facility failed to ensure drugs and biologicals were labeled properly; multiple opened multi-dose vials lacked open dates and expired medications were stored in medication rooms.
10NYCRR 415.21(a)(1) - The facility did not provide timely and complete radiology services; Resident #150's lumbar spine x-ray was delayed and not ordered in the electronic medical record as required.
10 NYCRR 415.12(l)(1) - The facility's infection control program failed to monitor and track antibiotic use for Resident #25, who was on long-term prophylactic antibiotics.
Report Facts
Date of survey completion: Jun 18, 2024
Start date of antibiotic use: Nov 22, 2020
Duration of antibiotic use: 4
Number of opened multi-dose vials without open date: 3
Expiration dates of expired medications: 202112
Expiration dates of expired medications: 202405
Expiration dates of expired medications: 202402
Date of delayed lumbar x-ray: Mar 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician Assistant #1 | Stated importance of reviewing and renewing MOLST forms for Resident #8 | |
| Social Worker #2 | Discussed review frequency and importance of MOLST forms and resident notification | |
| Registered Nurse #1 | Unit Manager | Discussed responsibilities for MOLST review and notification of x-ray orders |
| Director of Nursing | Provided expectations for MOLST review, antibiotic monitoring, and medication labeling | |
| Pharmacy Consultant | Responsible for medication regimen review and antibiotic stewardship monitoring | |
| Certified Nursing Assistant #9 | Observed leaving Resident #41 exposed during care | |
| Certified Nursing Assistant #8 | Commented on privacy expectations during care | |
| Pharmacy Technician | Responsible for checking medication storage rooms for expired or unlabeled medications | |
| Nurse Practitioner #1 | Ordered x-rays for Resident #150 and documented delays | |
| Medical Doctor | Expected all ordered x-rays to be completed for Resident #150 | |
| Administrator | Discussed expectations for medication storage and antibiotic stewardship |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Jun 18, 2024
Visit Reason
Multiple Level 2 deficiencies in standard health citations and life safety code citations, all corrected by August 16, 2024.
Findings
Multiple Level 2 deficiencies in standard health citations and life safety code citations, all corrected by August 16, 2024.
Deficiencies (11)
Antibiotic stewardship program
Drug regimen review, report irregular, act on
Label/store drugs and biologicals
Notify of changes (injury/decline/room, etc. )
Personal privacy/confidentiality of records
Radiology/other diagnostic services
Request/refuse/dscntnue trmnt;formlte adv dir
Emergency lighting
Fire alarm system - testing and maintenance
General requirements - other
Subdivision of building spaces - smoke barrie
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 8, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding an allegation of abuse reported by Resident #1 on 11/24/23 involving rough treatment by a Certified Nursing Assistant during a shower.
Complaint Details
The complaint investigation (#NY00328763) was substantiated for failure to timely report and investigate an abuse allegation made by Resident #1 on 11/24/23. The facility did not notify the Administrator or Department of Health within two hours and did not conduct a documented investigation.
Findings
The facility failed to report the allegation of abuse within the required two-hour timeframe to the Administrator and the New York State Department of Health. Additionally, the facility did not conduct a thorough investigation of the abuse allegation, with no documented evidence of investigation or interviews of involved staff or residents.
Deficiencies (2)
F 0609: The facility did not report an allegation of abuse involving Resident #1 within two hours to the Administrator and State Survey Agency as required.
F 0610: The facility failed to thoroughly investigate an allegation of abuse for Resident #1, with no documented evidence of investigation or interviews.
Report Facts
Residents affected: 1
Date of abuse allegation: Nov 24, 2023
Date survey completed: Feb 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | Involved in alleged rough treatment of Resident #1 | |
| Licensed Practical Nurse #1 | Documented Resident #1 complaint and notified social work | |
| Social Worker #2 | Notified of abuse allegation and considered it an allegation of abuse | |
| Director of Social Work #1 | Responsible for resident grievances, unaware of allegation until 2/6/24 | |
| Registered Nurse #1 | Reported allegation to former Director of Nursing | |
| Former Administrator | Not notified of abuse allegation | |
| Acting Administrator | Unaware why allegation was not reported or investigated | |
| Director of Nursing | Newly employed, could not locate investigation documentation |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Feb 8, 2024
Visit Reason
Two Level 2 standard health deficiencies related to investigation and reporting of alleged violations, corrected by March 22, 2024.
Findings
Two Level 2 standard health deficiencies related to investigation and reporting of alleged violations, corrected by March 22, 2024.
Deficiencies (2)
Investigate/prevent/correct alleged violation
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 21, 2023
Visit Reason
The visit was conducted as an abbreviated survey triggered by a complaint (Complaint #NY00322117) to assess whether the facility met professional standards of quality care.
Complaint Details
The survey was complaint-related, investigating Complaint #NY00322117. The complaint was substantiated as the facility failed to meet professional standards in medication administration for Resident #1.
Findings
The facility failed to ensure medications were administered according to policy for Resident #1, as medications were left unattended at the bedside and on the floor, and it was not verified that the resident swallowed the medications as ordered.
Deficiencies (1)
10 NYCRR 415.11(c)(3)(i) The facility did not ensure medications were never left unattended at Resident #1's bedside and did not verify that the resident swallowed the medications before signing off on the Medication Administration Record.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration observation and interview regarding failure to verify medication ingestion. |
| Director of Nursing | Director of Nursing | Provided statements on medication administration policy and expectations. |
| LPN #4 | Unit Manager | Provided statements on medication administration and refusal. |
| Nurse Practitioner #1 | Nurse Practitioner | Provided statements on medication administration recommendations and notification requirements. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 21, 2023
Visit Reason
One Level 2 deficiency for services provided meet professional standards, corrected by January 12, 2024.
Findings
One Level 2 deficiency for services provided meet professional standards, corrected by January 12, 2024.
Deficiencies (1)
Services provided meet professional standards
Inspection Report
Routine
Deficiencies: 3
Date: Oct 3, 2022
Visit Reason
The inspection was a standard routine survey conducted from 9/27/22 through 10/3/22 to assess compliance with regulatory requirements related to resident care, medication management, infection control, and food service.
Findings
The facility failed to provide appropriate catheter care to prevent urinary tract infections for two residents, did not implement gradual dose reductions for psychotropic medications for one resident, and served food and drink at unsafe and unappetizing temperatures on two units.
Deficiencies (3)
F 0690: The facility did not ensure appropriate care for residents with indwelling urinary catheters to prevent urinary tract infections. Catheter tubing and drainage bags were improperly handled and often touched the floor, increasing infection risk for Residents #106 and #120.
F 0758: The facility did not implement gradual dose reductions or behavioral interventions for psychotropic medications as clinically indicated. Resident #88 continued to receive antipsychotic medication without adequate indication or documented attempts to discontinue.
F 0804: The facility did not provide food and drink at safe and appetizing temperatures. Observations showed hot foods like lasagna were served below the required temperature and residents reported cold or lukewarm food and beverages on Units One and Two.
Report Facts
Physician order dosage: 100
Medication dosage: 25
Food temperature: 114
Food temperature: 121.1
Food temperature: 51
Food temperature: 70
Food temperature: 67
Food temperature: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding catheter care and infection control for Residents #106 and #120 |
| CNA #1 | Certified Nurse Aide | Observed and interviewed about catheter care and leg bag application for Resident #120 |
| RN #2 | Unit Manager | Interviewed about catheter tubing and drainage bag infection control responsibilities |
| RN #1 | Nurse Educator | Interviewed about nursing responsibilities for leg bag application and catheter care |
| Interim Director of Nursing | Infection Preventionist | Interviewed regarding catheter care policies and infection prevention |
| LPN #4 | Unit Manager | Described process for handling Consultant Pharmacist recommendations for Resident #88 |
| Consultant Pharmacist | Provided medication review and recommendation to discontinue Seroquel for Resident #88 | |
| MD | Medical Director | Interviewed regarding medication orders and discontinuation of Seroquel for Resident #88 |
| Registered Dietitian | RD | Interviewed about food temperature standards and observations during meal service |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Oct 3, 2022
Visit Reason
Multiple standard health and life safety code deficiencies, mostly Level 2, all corrected by November 25, 2022.
Findings
Multiple standard health and life safety code deficiencies, mostly Level 2, all corrected by November 25, 2022.
Deficiencies (9)
Bowel/bladder incontinence, catheter, uti
Criminal history record check process
Department criminal history review
Free from unnec psychotropic meds/prn use
Nutritive value/appear, palatable/prefer temp
Alcohol based hand rub dispenser (abhr)
Electrical systems - essential electric syste
Gas equipment - precautions for handling oxyg
Subdivision of building spaces - smoke barrie
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Nov 12, 2019
Visit Reason
The inspection was conducted as a complaint investigation regarding concerns about resident care, medication use, food service, and infection control at the facility.
Complaint Details
The complaint investigation (Complaint # NY00243378) focused on issues including inadequate personal hygiene care, unnecessary psychotropic medication use, food safety and quality concerns, improper food storage, and infection control lapses.
Findings
The facility was found deficient in providing adequate personal hygiene care, ensuring appropriate use of psychotropic medications, maintaining food safety and palatability, properly storing food items, and implementing effective infection prevention and control practices including proper linen handling and oxygen tubing management.
Deficiencies (5)
F 0677: The facility failed to ensure residents dependent on staff for activities of daily living received necessary grooming and personal hygiene care, evidenced by a resident with long jagged fingernails with brown debris.
F 0758: The facility did not ensure residents' drug regimens were free from unnecessary psychotropic medications, specifically lacking adequate indication for Risperidone use in one resident.
F 0804: The facility failed to provide food and drink that was palatable, attractive, and served at safe appetizing temperatures, with food items served cold or dry in two units.
F 0812: The facility did not store and distribute food in accordance with professional standards, with outdated and undated food items found in a unit kitchenette.
F 0880: The facility failed to implement an infection prevention and control program, including improper linen handling with dirty linens placed on the floor and oxygen nasal cannula tubing stored on the floor without protective barriers.
Report Facts
Food temperature: 85
Food temperature: 100
Food temperature: 104.5
Nail length: 1
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #11 | Certified Nursing Assistant | Mentioned in relation to nail care and forgetting to trim resident's nails |
| RN #1 | Unit Manager | Provided expectations for nail care and skin checks |
| Director of Nursing | Stated expectations for nail care and infection control practices | |
| Occupational Therapist | Provided education on nail care and contracture management | |
| Consultant Pharmacist | Recommended review of psychotropic medication necessity | |
| Food Service Director | Provided information on food temperature standards and food handling | |
| CNA #1 | Certified Nurse Aide | Commented on oxygen tubing storage practices |
| LPN #1 | Licensed Practical Nurse | Described oxygen tubing storage and change procedures |
| RN #6 | Registered Nurse | Commented on proper linen handling |
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