Inspection Reports for
Elderwood at Hamburg
5775 Maelou Drive, Hamburg, NY, 14075
Back to Facility ProfileCitations (last 6 years)
Citations (over 6 years)
7.5 citations/year
Citations are regulatory findings recorded during state inspections.
47% worse than New York average
New York average: 5.1 citations/yearCitations per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Citations: 2
Date: Jan 22, 2026
Visit Reason
The inspection was conducted following a complaint investigation regarding medication administration errors and resident safety concerns.
Complaint Details
The complaint investigation focused on medication administration errors for Resident #3, where medications were omitted and falsely documented as given. It also investigated falls of Residents #1 and #2 due to failure to follow care plans and safety protocols, resulting in fractures and injuries.
Findings
The facility failed to ensure Resident #3 received all ordered evening medications, resulting in minimal harm. Additionally, the facility failed to provide adequate supervision and safety measures for Residents #1 and #2, resulting in falls and fractures causing actual harm.
Citations (2)
F 0658: Resident #3 did not receive all evening medications as ordered, and the Licensed Practical Nurse documented medications as administered when they were not. The nursing supervisor and medical provider were not notified of the omissions.
F 0689: The facility failed to ensure adequate supervision and safety measures during bed mobility for Residents #1 and #2. Resident #1 fell from bed due to unlocked bed brakes and lack of two-person assist, sustaining a right elbow fracture. Resident #2 fell from bed with similar circumstances, sustaining a fractured left middle finger and multiple lacerations.
Report Facts
Residents reviewed: 6
Residents reviewed: 10
Medication count: 13
Staff educated: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Named in medication administration omission and false documentation |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding medication administration incident |
| Director of Nursing | Director of Nursing | Provided statements on medication omission and supervision failures |
| Medical Doctor #1 | Medical Doctor | Interviewed about notification and medication administration |
| Registered Nurse #4 | Unit Manager | Interviewed regarding medication incident and supervision |
| Licensed Practical Nurse Supervisor #1 | Nursing Supervisor | Interviewed about medication incident and fall investigations |
| Certified Nurse Aide #1 | Certified Nurse Aide | Involved in Resident #1 fall incident |
| Certified Nurse Aide #2 | Certified Nurse Aide | Involved in Resident #1 fall incident |
| Physician Assistant #1 | Physician Assistant | Evaluated Resident #1 after fall and fracture |
| Physical Therapist #1 | Physical Therapist | Provided therapy notes on Resident #1 after fall |
| Certified Nurse Aide #3 | Certified Nurse Aide | Involved in Resident #2 fall incident |
| Licensed Practical Nurse Supervisor #3 | Licensed Practical Nurse Supervisor | Interviewed about Resident #2 fall incident |
| Registered Nurse #2 | Educator | Interviewed about bed locking and care plan adherence |
| Director of Rehabilitation Services | Director of Rehabilitation Services | Interviewed about Resident #2 fall and care |
| Administrator | Administrator | Provided statements on medication and fall incidents |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 1
Date: Aug 28, 2025
Visit Reason
One isolated Level 2 deficiency related to reporting of alleged violations with no actual harm but potential for minor discomfort.
Findings
One isolated Level 2 deficiency related to reporting of alleged violations with no actual harm but potential for minor discomfort.
Citations (1)
Reporting of alleged violations
Inspection Report
Routine
Citations: 4
Date: Jun 4, 2025
Visit Reason
The inspection was a standard routine survey conducted to assess compliance with regulatory requirements related to resident rights, activities of daily living assistance, catheter care, and pain management.
Findings
The facility was found deficient in several areas including failure to honor resident preferences for shower frequency, untimely incontinent care, improper catheter care and infection control practices, and delayed pain management for a resident with unrelieved hip pain.
Citations (4)
F 0561: The facility did not ensure Resident #36 received showers twice a week as preferred, providing only one shower weekly due to staffing limitations.
F 0677: Resident #90 was not provided timely incontinent care after requesting to be changed, resulting in prolonged exposure to soiled conditions.
F 0690: Residents #45 and #96 with indwelling catheters did not receive appropriate catheter care; catheter bags and tubing were observed on the floor and enhanced barrier precautions were not consistently followed.
F 0697: Resident #9 experienced delayed pain management for right hip pain unrelieved by Tylenol; stronger analgesics were not promptly provided despite documented complaints and family requests.
Report Facts
Residents reviewed for shower preference: 5
Shower frequency preference: 2
Observation duration: 120
Pain medication dosage: 650
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Unit Manager | Named in relation to delayed pain management for Resident #9 and oversight of care. |
| Certified Nurse Aide #6 | Certified Nurse Aide | Mentioned in relation to failure to provide Resident #36 with a shower and documentation of sponge bath. |
| Certified Nurse Aide #11 | Certified Nurse Aide | Observed providing incontinent care late to Resident #90 and not following infection control for catheter care. |
| Director of Nursing | Director of Nursing | Provided statements on expectations for resident preferences, incontinent care, catheter care, and pain management. |
| Physician Assistant #1 | Physician Assistant | Involved in pain management orders and interviewed about expectations for timely notification. |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 10
Date: Jun 4, 2025
Visit Reason
Multiple isolated Level 2 deficiencies related to ADL care, bowel/bladder incontinence, pain management, and self-determination. Life Safety Code deficiencies included aisle width, building construction, electrical systems, fire drills, illumination, and trash containers with pattern or isolated scope.
Findings
Multiple isolated Level 2 deficiencies related to ADL care, bowel/bladder incontinence, pain management, and self-determination. Life Safety Code deficiencies included aisle width, building construction, electrical systems, fire drills, illumination, and trash containers with pattern or isolated scope.
Citations (10)
ADL care provided for dependent residents
Bowel/bladder incontinence, catheter, uti
Pain management
Self-determination
Aisle, corridor, or ramp width
Building construction type and height
Electrical systems - essential electric syste
Fire drills
Illumination of means of egress
Soiled linen and trash containers
Inspection Report
Capacity: 60
Citations: 1
Date: Feb 6, 2024
Visit Reason
One widespread Level 2 deficiency related to reporting to the national health safety network with no actual harm but potential for minor discomfort.
Findings
One widespread Level 2 deficiency related to reporting to the national health safety network with no actual harm but potential for minor discomfort.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: Nov 6, 2023
Visit Reason
One widespread Level 2 deficiency related to reporting to the national health safety network with no actual harm but potential for minor discomfort.
Findings
One widespread Level 2 deficiency related to reporting to the national health safety network with no actual harm but potential for minor discomfort.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: Oct 30, 2023
Visit Reason
One widespread Level 2 deficiency related to reporting to the national health safety network with no actual harm but potential for minor discomfort.
Findings
One widespread Level 2 deficiency related to reporting to the national health safety network with no actual harm but potential for minor discomfort.
Citations (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 19
Date: Oct 3, 2023
Visit Reason
Multiple isolated Level 2 deficiencies related to ADL care, accident hazards, medication errors, resident rights, physical restraints, and several life safety code issues. Most deficiencies corrected as of November 2023.
Findings
Multiple isolated Level 2 deficiencies related to ADL care, accident hazards, medication errors, resident rights, physical restraints, and several life safety code issues. Most deficiencies corrected as of November 2023.
Citations (19)
ADL care provided for dependent residents
Free of accident hazards/supervision/devices
Free of medication error rts 5 prcnt or more
Posted nurse staffing information
Resident rights/exercise of rights
Residents are free of significant med errors
Right to be free from physical restraints
Aisle, corridor, or ramp width
Building construction type and height
Cooking facilities
Corridor - doors
Corridors - construction of walls
Electrical systems - essential electric syste
Evacuation and relocation plan
Exit signage
Fire alarm system - testing and maintenance
Gas equipment - cylinder and container storag
Hazardous areas - enclosure
Subdivision of building spaces - smoke barrie
Inspection Report
Capacity: 60
Citations: 1
Date: Nov 28, 2022
Visit Reason
One widespread Level 2 deficiency related to reporting to the national health safety network with no actual harm but potential for minor discomfort.
Findings
One widespread Level 2 deficiency related to reporting to the national health safety network with no actual harm but potential for minor discomfort.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: Nov 21, 2022
Visit Reason
One widespread Level 2 deficiency related to reporting to the national health safety network with no actual harm but potential for minor discomfort.
Findings
One widespread Level 2 deficiency related to reporting to the national health safety network with no actual harm but potential for minor discomfort.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 1
Date: Nov 15, 2022
Visit Reason
One widespread Level 2 deficiency related to reporting to the national health safety network with no actual harm but potential for minor discomfort.
Findings
One widespread Level 2 deficiency related to reporting to the national health safety network with no actual harm but potential for minor discomfort.
Citations (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 1
Date: Sep 1, 2022
Visit Reason
One isolated Level 2 deficiency related to free of accident hazards/supervision/devices corrected as of October 2022.
Findings
One isolated Level 2 deficiency related to free of accident hazards/supervision/devices corrected as of October 2022.
Citations (1)
Free of accident hazards/supervision/devices
Inspection Report
Routine
Citations: 2
Date: Oct 13, 2021
Visit Reason
The survey was conducted as a Standard survey to assess compliance with regulatory requirements related to resident care and facility operations.
Findings
The facility failed to ensure that a resident unable to perform activities of daily living received necessary grooming and hygiene care, specifically shaving and nail care. Additionally, the facility did not ensure that pureed food was palatable and prepared according to dietary standards, resulting in unappetizing meals for residents.
Citations (2)
F 0677: The facility did not provide necessary grooming and personal hygiene care, including shaving and nail care, for a resident who required extensive assistance and supervision.
F 0804: The facility failed to ensure food was palatable and prepared properly, with pureed green beans and egg noodles being watery, pasty, and lacking flavor.
Report Facts
Residents affected: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Did not offer shaving or nail care to Resident #54 during morning care | |
| Registered Nurse (RN) #1 Unit Manager | Stated CNA staff should provide shaving and nail care as part of morning care | |
| Director of Nursing (DON) | Expected residents to be shaved with morning care and nail care on shower days | |
| Dietary Services (DDS) | Observed and reported pureed food preparation issues and poor taste | |
| Diet Tech (DT) | Prepared pureed food without following recipes or proper technique | |
| Speech Language Pathologist (SLP) | Provided expectations for pureed food consistency | |
| Registered Dietitian (RD) | Commented on proper pureed food preparation and consistency |
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