Inspection Reports for
Elderwood at Hamburg
5775 Maelou Drive, Hamburg, NY, 14075
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Deficiencies: 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.
Deficiencies (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
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The inspection was conducted as an abbreviated survey triggered by Complaint #2596250 regarding delayed reporting of alleged abuse at the facility.
Complaint Details
Complaint #2596250 was substantiated. The allegation involved delayed reporting of abuse where Certified Nurse Aide #1 witnessed Certified Nurse Aide #2 slap Resident #1 but reported the incident eleven days later due to fear of retaliation.
Findings
The facility failed to report an allegation of physical abuse involving Resident #1 to the Administrator and State Survey Agency within the required two-hour timeframe. The abuse incident occurred on 2025-08-09 but was not reported to the Administrator until 2025-08-20, resulting in delayed notification to the New York State Department of Health.
Deficiencies (1)
F 0609: The facility did not ensure timely reporting of suspected abuse. Staff failed to report an allegation of physical abuse to the Administrator immediately, causing delayed reporting to the State Survey Agency beyond the required two-hour timeframe.
Report Facts
Residents reviewed: 3
Days delay in reporting: 11
Time of alleged incident: 7.32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Witnessed abuse and delayed reporting due to fear of retaliation | |
| Certified Nurse Aide #2 | Alleged perpetrator of abuse, denied slapping Resident #1 | |
| Licensed Practical Nurse #1 | Received abuse report from CNA #1 and reported to Director of Nursing | |
| Director of Nursing | Interviewed regarding reporting requirements and incident | |
| Registered Nurse Unit Manager #2 | Interviewed regarding abuse reporting timeframes | |
| Administrator | Interviewed regarding delayed reporting and facility policy |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 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.
Deficiencies (1)
Reporting of alleged violations
Inspection Report
Routine
Deficiencies: 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.
Deficiencies (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
Deficiencies: 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.
Deficiencies (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
Deficiencies: 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.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 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.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 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.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 3, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on complaints regarding inadequate care and safety hazards for residents at the facility.
Complaint Details
The complaint investigations (Complaint #NY00322837 and #NY00320987) revealed failures in providing necessary ADL assistance and supervision, improper incontinent care, and failure to follow care plans leading to resident falls. The complaints were substantiated with observations, interviews, and record reviews.
Findings
The facility failed to ensure proper incontinent care and infection control for Resident #47, and did not follow care plans for Residents #60 and #94, resulting in falls and safety risks. Staff did not adhere to required hygiene and transfer procedures.
Deficiencies (2)
F 0677: The facility did not ensure proper hand hygiene and glove changes during bowel incontinence care for Resident #47, risking infection control.
F 0689: The facility did not ensure the resident environment was free from accident hazards and failed to follow care plans for Residents #60 and #94, resulting in falls.
Report Facts
Complaint number: Complaint #NY00322837 related to incontinent care
Complaint number: Complaint #NY00320987 related to resident falls
Dates of incidents: Falls incidents on 7/5/23, 7/28/23, and 4/1/23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nurse Aide | Named in finding for improper glove use and hand hygiene during incontinent care of Resident #47 |
| CNA #8 | Certified Nurse Aide | Witnessed and commented on improper glove use during Resident #47 care |
| LPN #8 | Licensed Practical Nurse | Provided interview on proper hand hygiene and infection control expectations |
| RN #4 | Registered Nurse Unit Manager | Provided interview on expectations for incontinent care and infection control |
| Director of Nursing | Director of Nursing | Provided interview on expectations for incontinent care and glove use |
| CNA #5 | Certified Nursing Assistant | Named in fall incident for Resident #60 due to improper use of sit to stand lift |
| CNA #1 | Certified Nursing Assistant | Named in fall incident for Resident #60 due to failure to follow care plan |
| LPN #9 | Licensed Practical Nurse Supervisor | Provided interview regarding fall incident and staffing issues |
| LPN #10 | Licensed Practical Nurse | Completed incident report for Resident #94 fall |
| CNA #6 | Certified Nursing Assistant | Named in fall incident for Resident #94 due to failure to follow two-person assist care plan |
| Administrator | Administrator | Provided interview on expectations for following care plans |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 3, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of inadequate care, improper use of restraints, medication errors, and failure to follow care plans.
Complaint Details
The complaint investigations included allegations of undignified feeding assistance, improper use of restraints, inadequate hygiene practices during incontinent care, failure to follow care plans leading to falls, failure to post nurse staffing data, and medication administration errors. Several residents were specifically reviewed and found affected.
Findings
The facility was found to have multiple deficiencies including failure to provide dignified feeding assistance, improper use of physical restraints without physician orders, inadequate hand hygiene during incontinent care, failure to follow resident care plans resulting in falls, failure to post nurse staffing information as required, and medication administration errors with omitted doses and late administration.
Deficiencies (6)
10 NYCRR 415.5(a) - The facility did not ensure staff provided feeding assistance at residents' eye level, resulting in undignified care for multiple residents.
10 NYCRR 415.4(a)(2)(iii) - Resident #83 was physically restrained with a seatbelt on their wheelchair without a physician's order or care plan documentation.
10 NYCRR 415.12(a)(3) - CNA failed to change gloves and perform proper hand hygiene during bowel incontinence care for Resident #47, risking cross-contamination.
10 NYCRR 415.12(h)(2) - Staff did not follow residents' care plans for assistance and supervision, resulting in falls for Residents #60 and #94.
10 NYCRR 415.13 - The facility failed to post daily nurse staffing information for three days and did not maintain records for 18 months as required.
10 NYCRR 415.12(m)(1) - Medication error rate exceeded 5% due to omitted and late administration of medications for Resident #115 without proper notification to the provider.
Report Facts
Medication error rate: 7.41
Falls: 23
Medication opportunities observed: 27
Residents affected: 7
Residents affected: 3
Residents affected: 2
Residents affected: 3
Days nurse staffing information not posted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Unit Manager | Named in feeding assistance and restraint findings |
| LPN #6 | Licensed Practical Nurse | Named in feeding assistance findings |
| OTR | Occupational Therapist Registered | Named in feeding assistance and restraint findings |
| CNA #7 | Certified Nursing Assistant | Named in incontinent care hygiene deficiency |
| LPN #8 | Licensed Practical Nurse | Named in medication administration error |
| RN #4 | Unit Manager | Named in medication administration error and feeding assistance findings |
| Director of Nursing | Director of Nursing | Named in restraint and medication administration findings |
| Administrator | Administrator | Named in restraint and staffing posting findings |
| Physician Assistant | Physician Assistant | Named in restraint and medication administration findings |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 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.
Deficiencies (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
Deficiencies: 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.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 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.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 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.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 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.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Routine
Deficiencies: 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.
Deficiencies (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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