Inspection Reports for
Elderwood at Lockport
104 Old Niagara Road, Lockport, NY, 14094
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 2
Date: May 2, 2025
Visit Reason
The inspection was a Standard survey conducted to assess compliance with care and infection prevention regulations at the nursing home.
Findings
The facility failed to ensure that residents unable to perform activities of daily living received necessary grooming assistance, specifically for one resident with unwanted facial hair. Additionally, the facility did not maintain an effective infection prevention and control program, as staff failed to wear gowns during incontinent care for a resident with ESBL infection.
Deficiencies (2)
F 0677: The facility did not provide adequate care and assistance for activities of daily living, resulting in one resident having visible unwanted facial hair despite policies requiring shaving on shower days or when visible hair is noticed.
F 0880: The facility failed to implement an infection prevention and control program by not ensuring staff wore gowns during incontinent care for a resident with ESBL infection, risking cross contamination.
Report Facts
Residents affected: 1
Residents affected: 1
Colony count: 100000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding grooming care and shaving practices for Resident #6 |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding shaving schedule and practices for Resident #6 |
| Registered Nurse #1 | Unit Manager | Interviewed about shaving policies for residents |
| Registered Nurse #2 | Registered Nurse | Interviewed about shaving practices for residents |
| Director of Nursing | Director of Nursing | Interviewed about shaving responsibilities and infection control expectations |
| Certified Nurse Assistant #3 | Certified Nurse Assistant | Observed and interviewed regarding gown use during incontinent care for Resident #54 |
| Certified Nurse Assistant #4 | Certified Nurse Assistant | Observed and interviewed regarding gown use during incontinent care for Resident #54 |
| Registered Nurse Unit Manager #3 | Registered Nurse Unit Manager | Interviewed about infection control expectations for Resident #54 |
| Assistant Director of Nursing/Infection Preventionist | Assistant Director of Nursing/Infection Preventionist | Provided infection control policies and interviewed about gown use requirements |
| Physician #1 | Physician | Interviewed about expectations for staff gown and glove use during incontinent care |
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 5
Date: May 2, 2025
Visit Reason
Certification Survey with 2 health and 3 life safety code citations including ADL care, infection prevention, electrical systems, fire drills, and sprinkler system deficiencies, all corrected by mid-2025.
Findings
Certification Survey with 2 health and 3 life safety code citations including ADL care, infection prevention, electrical systems, fire drills, and sprinkler system deficiencies, all corrected by mid-2025.
Deficiencies (5)
ADL care provided for dependent residents
Infection prevention & control
Electrical systems - essential electric system
Fire drills
Sprinkler system - maintenance and testing
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: Jun 6, 2023
Visit Reason
Complaint Survey with 6 health and 9 life safety code citations including ADL care, infection prevention, nurse staffing, resident rights, electrical systems, emergency lighting, fire alarm, gas equipment storage, means of egress, portable fire extinguishers, sprinkler system, and smoke barrier deficiencies, mostly corrected by July 2023.
Findings
Complaint Survey with 6 health and 9 life safety code citations including ADL care, infection prevention, nurse staffing, resident rights, electrical systems, emergency lighting, fire alarm, gas equipment storage, means of egress, portable fire extinguishers, sprinkler system, and smoke barrier deficiencies, mostly corrected by July 2023.
Deficiencies (15)
ADL care provided for dependent residents
Department criminal history review
Infection prevention & control
Posted nurse staffing information
Resident rights/exercise of rights
Sufficient nursing staff
Electrical systems - essential electric system
Emergency lighting
Fire alarm system - testing and maintenance
Gas equipment - cylinder and container storage
Means of egress - general
Means of egress requirements - other
Portable fire extinguishers
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrier
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations that residents did not receive necessary assistance with activities of daily living, including toileting and showering, and concerns about insufficient nursing staff to meet resident needs.
Complaint Details
The complaint investigation (NY00316113) found that residents did not receive assistance with toileting and showering as per their care plans, and the facility was understaffed, leading to unmet resident needs and missed medication administration.
Findings
The facility failed to provide adequate assistance with activities of daily living for residents unable to care for themselves, including toileting and showering as per care plans. Additionally, the facility did not maintain sufficient nursing staff to meet resident needs, resulting in delayed call light responses, unmade beds, missed medication administration, and inadequate care.
Deficiencies (2)
F 0677: The facility did not ensure residents received necessary assistance with activities of daily living, including toileting and showering, as per their care plans for Residents #39, #74, and #101.
F 0725: The facility failed to provide sufficient nursing staff on all shifts and units, resulting in delayed call light responses, missed toileting and incontinent care, unmade beds, and missed medication administration for multiple residents.
Report Facts
Residents reviewed for ADL assistance: 6
Facility average daily census: 105
Residents on East Unit: 42
Minimum CNA staffing shortfalls: 1.5
Number of residents with missed medication documentation: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #10 | Certified Nursing Assistant | Named in failure to provide incontinent care to Resident #39 on 6/2/23. |
| RN UM #1 | Registered Nurse Unit Manager | Provided statements about staffing and call light response on East Unit. |
| DON | Director of Nursing | Provided multiple statements regarding care plans, staffing, and deficiencies. |
| LPN #2 | Licensed Practical Nurse | Reported being the only nurse on East Unit evening shift 6/4/23 and inability to complete medication pass. |
| ADON | Assistant Director of Nursing | Worked evening shift as CNA on 6/4/23 due to no aide and commented on staffing shortages. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jun 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on allegations regarding resident dignity, assistance with activities of daily living, staffing sufficiency, infection control, and medication administration at Elderwood at Lockport.
Complaint Details
The complaint investigation (NY00316113) was triggered by allegations that the facility failed to provide dignified care, adequate assistance with ADLs, sufficient staffing, proper infection control, and complete medication administration.
Findings
The facility failed to ensure residents were treated with dignity, received adequate assistance with toileting and personal hygiene, maintained sufficient nursing staff to meet resident needs, and implemented proper infection control practices. Additionally, medication administration was incomplete on one evening shift and nurse staffing information was not posted correctly.
Deficiencies (5)
F 0550: The facility did not ensure Resident #66 was treated with respect and dignity by a Certified Nurse Aide during morning care, including inappropriate staff comments.
F 0677: The facility failed to provide necessary assistance with activities of daily living, including toileting and showering, for Residents #39, #74, and #101 as per their care plans.
F 0725: The facility did not provide enough nursing staff daily to meet resident needs, resulting in delayed call light responses, incomplete toileting/incontinence care, unmade beds, and missed medication administration on the East Unit evening shift of 6/4/23.
F 0732: The facility did not post daily nurse staffing information including resident census as required, with posted reports showing a census of zero despite a census of 103 residents.
F 0880: The facility failed to maintain infection prevention and control practices for Residents #35 and #66, including inadequate hand hygiene during fecal incontinence care and pressure sore treatment, and improper technique when emptying a urinary drainage bag.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 26
Average daily census: 105
Minimum CNA staffing shortfalls: 1.5
Call light wait times: 81
Medication administration missed: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in infection control deficiency related to wound care and urinary catheter care |
| CNA #1 | Certified Nurse Aide | Named in dignity and infection control deficiencies related to resident care |
| CNA #10 | Certified Nurse Assistant | Named in ADL assistance deficiency for Resident #39 |
| CNA #2 | Certified Nurse Assistant | Named in ADL assistance deficiency for Resident #74 and staffing issues |
| LPN #2 | Licensed Practical Nurse | Named in medication administration deficiency on 6/4/23 evening shift |
| RN UM #1 | Registered Nurse Unit Manager | Named in dignity and infection control deficiencies and staffing issues |
| DON | Director of Nursing | Named in multiple interviews regarding staffing, infection control, and overall facility operations |
| ADON | Assistant Director of Nursing | Named in staffing and medication administration discussions |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jun 27, 2022
Visit Reason
Covid-19 Survey with a Level 2 citation for reporting to the national health safety network, widespread scope, not corrected as of report.
Findings
Covid-19 Survey with a Level 2 citation for reporting to the national health safety network, widespread scope, not corrected as of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 22, 2021
Visit Reason
Covid-19 Survey with a Level 2 citation for infection prevention & control, isolated scope, corrected by January 7, 2022.
Findings
Covid-19 Survey with a Level 2 citation for infection prevention & control, isolated scope, corrected by January 7, 2022.
Deficiencies (1)
Infection prevention & control
Inspection Report
Routine
Deficiencies: 2
Date: Jul 30, 2021
Visit Reason
The inspection was a Standard Survey conducted to assess compliance with regulatory requirements related to menu adherence and infection prevention and control practices.
Findings
The facility failed to follow the prepared menus for mechanically altered diets by substituting ground pork with gravy instead of Polish sausage. Additionally, the facility did not maintain proper infection prevention and control practices for residents with indwelling urinary catheters, as catheter drainage bags and tubing were observed in direct contact with the floor without barriers.
Deficiencies (2)
F 0803: The facility did not follow the prepared menus for mechanically altered diets on 7/28/21, providing ground pork with gravy instead of Polish sausage to residents requiring puree and ground consistencies.
F 0880: The facility failed to establish and maintain an infection prevention and control program, as indwelling urinary catheter drainage bags and tubing for Residents #43 and #60 were observed directly on the floor without barriers, increasing infection risk.
Report Facts
Residents affected: 15
Residents affected: 2
Catheter size: 16
Balloon size: 5
Balloon size: 10
UTI protocol fluid amount: 240
UTI protocol duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding menu substitution and food preparation practices | |
| Registered Dietitian | Interviewed regarding menu adherence | |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding expectations for reporting catheter bag placement |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding infection control issues with catheter bags on floor |
| Registered Nurse Unit Manager #1 | RN UM | Interviewed regarding catheter bag contamination risk |
| Registered Nurse Unit Manager #2 | RN UM | Interviewed regarding catheter tubing contact with floor |
| Director of Nursing | DON | Interviewed regarding infection control and catheter bag placement |
| Regional RN Consultant | Interviewed regarding catheter bag cleaning and placement | |
| Administrator | Interviewed regarding catheter bag affixation to bed | |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding catheter bag handling and barriers |
| Certified Nursing Assistant #3 | CNA | Interviewed regarding catheter bag placement and handling |
| Resident #60's Physician | Physician | Interviewed regarding catheter bag infection risk |
Viewing
Loading inspection reports...
