Inspection Reports for
Elderwood at Grand Island
2850 Grand Island Blvd, Grand Island, NY, 14072
Back to Facility Profile6 Reports
Inspection Report — Dec 2, 2025
Complaint Investigation State
Date: Dec 2, 2025
Visit Reason
State-compiled facility profile showing 20 inspections from 2022 to 2025 with deficiency and enforcement history.
Complaint Details
The state logged 131 complaints about this facility; 23 led to on-site inspections.
Findings
Across 20 inspections, 15 had no citations while 5 resulted in 30 citations total, mostly Level 2 minor potential harm deficiencies in both standard health and Life Safety Code categories. The facility had 131 complaints with 23 on-site inspections and one enforcement action with fines.
Citations (28)
Standard Health Citation — quality of care: Reporting Of Alleged Violations found deficient in multiple complaint inspections.
Standard Health Citation — quality of care: Department Criminal History Review deficiency noted.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan was deficient.
Standard Health Citation — quality of care: Reasonable Accommodations Needs/preferences not met.
Standard Health Citation — quality of care: Rn 8 Hrs/7 Days/wk, Full Time Don staffing deficiency.
Standard Health Citation — quality of care: Services Provided Meet Professional Standards found deficient.
Standard Health Citation — quality of care: Use Of Outside Resources was deficient.
Life Safety Code Citation — NFPA requirements: Egress Doors found deficient.
Life Safety Code Citation — NFPA requirements: Emergency Lighting was deficient.
Life Safety Code Citation — NFPA requirements: Fire Drills found deficient.
Life Safety Code Citation — NFPA requirements: Illumination Of Means Of Egress was deficient.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General found deficient.
Life Safety Code Citation — NFPA requirements: Multiple Occupancies found deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation was deficient.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrier found deficient.
Life Safety Code Citation — NFPA requirements: Corridors - Construction Of Walls found deficient.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Power Cords And Extensions deficient.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Other found deficient.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Installation was deficient.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance deficient.
Life Safety Code Citation — NFPA requirements: Fire Drills found deficient.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storage deficient.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure found deficient.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General found deficient.
Life Safety Code Citation — NFPA requirements: Means Of Egress Requirements - Other found deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficient.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrier found deficient.
Standard Health Citation — quality of care: Free From Abuse And Neglect deficiency noted.
Report Facts
Inspections on page: 20
Total violations/deficiencies cited: 30
Inspections with violations: 5
Inspections without violations: 15
Total complaints: 131
On-site inspections from complaints: 23
Citations issued from complaints: 3
Enforcement actions: 1
Total fines: 2000
Inspection Report — Dec 2, 2025
Abbreviated Survey CMS
Date: Dec 2, 2025
Visit Reason
The visit was conducted as an abbreviated survey triggered by Complaint #2674904 concerning alleged abuse at the facility.
Complaint Details
Complaint #2674904 was substantiated. The complaint involved delayed reporting of physical abuse of Resident #1 by staff. The abuse incident occurred on 11/18/2025 but was not reported to the Administrator until 11/20/2025, resulting in a two-day delay in reporting to the State Agency.
Findings
The facility failed to report an allegation of physical abuse immediately to the Administrator and the State Survey Agency, resulting in delayed reporting beyond the required two-hour timeframe. The investigation confirmed that a staff member grabbed a resident's hair and slammed their face into the bed, but the abuse was reported one day late.
Citations (1)
F 0609: The facility did not ensure timely reporting of suspected abuse, neglect, or theft to proper authorities. Staff delayed reporting an allegation of physical abuse involving Resident #1 by more than two hours, violating facility policy and state regulations.
Report Facts
Residents reviewed: 3
Residents affected: 1
Delay in reporting: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Named in abuse allegation for grabbing Resident #1's hair and slamming their face into the bed | |
| Certified Nursing Assistant #2 | Witnessed abuse, delayed reporting due to fear of retaliation, eventually reported abuse | |
| Registered Nurse #1 | Nurse Supervisor | Received abuse report from Certified Nursing Assistant #2 and questioned delay in reporting |
| Registered Nurse #2 | Unit Manager | Commented on expected reporting procedures and delay |
| Director of Nursing | Acknowledged delay in reporting and confirmed investigation dates | |
| Administrator | Stated that delay in reporting was unacceptable and should have been immediate |
Inspection Report — Dec 6, 2024
Routine CMS
Date: Dec 6, 2024
Visit Reason
The inspection was a Standard survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to ensure call light accessibility for a resident, lack of a comprehensive care plan for a resident at high risk of elopement, failure to implement provider orders for eye care, improper use of the Director of Nursing as a charge nurse during high census periods, and absence of dental services either onsite or through outside arrangements.
Citations (5)
F 0558: The facility did not ensure Resident #1's call light was within reach as planned, preventing timely use and assistance.
F 0656: The facility failed to develop a comprehensive care plan with measurable objectives for Resident #18, who was at high risk for elopement and wandering.
F 0658: Provider orders for lid hygiene recommended by an optometrist for Resident #37 were not implemented, resulting in delayed treatment.
F 0727: The Director of Nursing worked as a charge nurse during overnight shifts when the facility census exceeded 60, contrary to policy.
F 0840: The facility did not employ a dentist nor had an arrangement with an outside dental service, leaving residents without routine or emergency dental care since April 2024.
Report Facts
Total licensed beds: 90
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Named in findings related to care planning, optometrist order follow-up, and dental services |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Documented Resident #18's wandering and exit seeking behaviors |
| Director of Nursing | Director of Nursing | Named in findings related to charge nurse duties and dental services |
| Nurse Practitioner #1 | Nurse Practitioner | Responded to optometrist recommendation message for Resident #37 |
| Registered Nurse Nursing Supervisor #1 | Registered Nurse Nursing Supervisor | Involved in communication regarding optometrist recommendations |
Inspection Report — May 5, 2023
Abbreviated Survey CMS
Date: May 5, 2023
Visit Reason
The visit was conducted as an abbreviated survey triggered by complaint #NY00313153 to investigate alleged violations involving abuse at the facility.
Complaint Details
The complaint investigation was substantiated. The incident occurred on 3/9/23 and involved verbal abuse by CNA #1 towards Resident #1. The abuse was reported late on 3/21/23 instead of immediately as required.
Findings
The facility failed to ensure that an alleged verbal abuse incident involving Resident #1 was reported immediately, within the required two-hour timeframe, to the appropriate officials. The incident involved a Certified Nurse Aide verbally threatening the resident, and the delay in reporting was confirmed through interviews with staff and administrators.
Citations (1)
F 0609: The facility did not timely report suspected abuse involving Resident #1. The verbal abuse incident was not reported to the Administrator or State Department of Health within the required two-hour timeframe.
Report Facts
Date of incident: Mar 9, 2023
Date reported: Mar 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Involved in verbal abuse incident with Resident #1 |
| CNA #2 | Certified Nurse Aide | Witnessed abuse and intervened, reported incident to LPN #1 |
| LPN #1 | Licensed Practical Nurse Unit Manager | Received report from CNA #2 but delayed reporting to Administrator |
| RN #1 | Registered Nurse Interim Director of Nursing | Interim DON at time of incident, confirmed abuse was not reported immediately |
| Administrator #1 | Facility Administrator | Unaware of abuse until 3/21/23, confirmed late reporting |
Inspection Report — May 3, 2023
Annual Inspection CMS
Date: May 3, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Elderwood at Grand Island nursing home.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Dec 6, 2021
Routine CMS
Date: Dec 6, 2021
Visit Reason
The inspection was a standard survey conducted to assess compliance with care requirements for residents unable to perform activities of daily living, specifically focusing on grooming and personal hygiene.
Findings
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary nail care. Two residents were observed with long and dirty fingernails, and staff interviews confirmed that nail care was not provided as required.
Citations (1)
F 0677: The facility did not provide nail care to residents unable to perform activities of daily living, resulting in long and dirty fingernails for two residents despite care plans and policies requiring nail care.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Responsible for ensuring CNAs cleaned and trimmed residents' fingernails; admitted failure to notice need for nail care. |
| CNA #2 | Certified Nursing Assistant | Provided morning care but did not clean residents' fingernails on specified dates. |
| RN Unit Manager #2 | Registered Nurse Unit Manager | Stated CNAs were responsible for cleaning fingernails during showers and nurses for trimming nails of residents with diabetes. |
| Director of Nursing | Director of Nursing | Stated expectation that all residents' fingernails be clean and trimmed for safety and infection control. |
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