Inspection Reports for
Elderwood at Grand Island
2850 Grand Island Blvd, Grand Island, NY, 14072
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
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.
Deficiencies (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
Routine
Census: 78
Capacity: 90
Deficiencies: 5
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.
Deficiencies (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
Facility census: 78
Total licensed beds: 90
Deficiencies cited: 5
Facility census range: 78
Facility census range: 82
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
Complaint Investigation
Capacity: 60
Deficiencies: 14
Date: Dec 6, 2024
Visit Reason
Multiple standard health and life safety code deficiencies identified, all corrected within weeks to months.
Findings
Multiple standard health and life safety code deficiencies identified, all corrected within weeks to months.
Deficiencies (14)
Department criminal history review — Standard Health Inspection Citation
Develop/implement comprehensive care plan — Standard Health Inspection Citation
Reasonable accommodations needs/preferences — Standard Health Inspection Citation
Rn 8 hrs/7 days/wk, full time don — Standard Health Inspection Citation
Services provided meet professional standards — Standard Health Inspection Citation
Use of outside resources — Standard Health Inspection Citation
Egress doors — Standard Life Safety Code Citation
Emergency lighting — Standard Life Safety Code Citation
Fire drills — Standard Life Safety Code Citation
Illumination of means of egress — Standard Life Safety Code Citation
Means of egress - general — Standard Life Safety Code Citation
Multiple occupancies — Standard Life Safety Code Citation
Sprinkler system - installation — Standard Life Safety Code Citation
Subdivision of building spaces - smoke barrier — Standard Life Safety Code Citation
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: May 5, 2023
Visit Reason
One standard health citation for reporting of alleged violations, corrected within 2 months.
Findings
One standard health citation for reporting of alleged violations, corrected within 2 months.
Deficiencies (1)
Reporting of alleged violations — Standard Health Inspection Citation
Inspection Report
Abbreviated Survey
Deficiencies: 1
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.
Deficiencies (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
Annual Inspection
Deficiencies: 0
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
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: May 3, 2023
Visit Reason
Multiple life safety code citations related to fire safety systems and building construction, all corrected within weeks.
Findings
Multiple life safety code citations related to fire safety systems and building construction, all corrected within weeks.
Deficiencies (13)
Corridors - construction of walls — Standard Life Safety Code Citation
Electrical equipment - power cords and extension cords — Standard Life Safety Code Citation
Electrical systems - other — Standard Life Safety Code Citation
Fire alarm system - installation — Standard Life Safety Code Citation
Fire alarm system - testing and maintenance — Standard Life Safety Code Citation
Fire drills — Standard Life Safety Code Citation
Gas equipment - cylinder and container storage — Standard Life Safety Code Citation
Hazardous areas - enclosure — Standard Life Safety Code Citation
Means of egress - general — Standard Life Safety Code Citation
Means of egress requirements - other — Standard Life Safety Code Citation
Sprinkler system - installation — Standard Life Safety Code Citation
Sprinkler system - maintenance and testing — Standard Life Safety Code Citation
Subdivision of building spaces - smoke barrier — Standard Life Safety Code Citation
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 23, 2022
Visit Reason
One standard health citation for free from abuse and neglect, corrected within 2 months.
Findings
One standard health citation for free from abuse and neglect, corrected within 2 months.
Deficiencies (1)
Free from abuse and neglect — Standard Health Inspection Citation
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 4, 2022
Visit Reason
One standard health citation for reporting to national health safety network, widespread scope, not yet corrected.
Findings
One standard health citation for reporting to national health safety network, widespread scope, not yet corrected.
Deficiencies (1)
Reporting - national health safety network — Standard Health Inspection Citation
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 28, 2022
Visit Reason
One standard health citation for reporting to national health safety network, widespread scope, not yet corrected.
Findings
One standard health citation for reporting to national health safety network, widespread scope, not yet corrected.
Deficiencies (1)
Reporting - national health safety network — Standard Health Inspection Citation
Inspection Report
Routine
Deficiencies: 1
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.
Deficiencies (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. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 6, 2021
Visit Reason
One standard health citation for ADL care provided for dependent residents, corrected within weeks.
Findings
One standard health citation for ADL care provided for dependent residents, corrected within weeks.
Deficiencies (1)
ADL care provided for dependent residents — Standard Health Inspection Citation
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