Inspection Reports for
Elderwood at Waverly
37 North Chemung Street, Waverly, NY, 14892
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Inspection Report — Mar 11, 2026
Complaint Investigation State
Date: Mar 11, 2026
Visit Reason
State-compiled facility profile showing 9 inspections from 2022 to 2026 with citation and enforcement history.
Complaint Details
The state logged 180 complaints about this facility; 17 led to on-site inspections. The facility received 99.5 complaints per 100 beds versus a statewide rate of 57.4. Eleven citations resulted from those complaints.
Findings
Across 9 inspections, 58 citations were issued including 32 standard health and 26 life safety code citations. The facility had 3 enforcement actions totaling $14,000 in fines and multiple citations with varying severity levels, including immediate jeopardy findings.
Citations (53)
Free From Abuse And Neglect: Standard Health Citation — quality of care with immediate jeopardy and pattern scope found on March 11, 2026, corrected April 22, 2026.
Free From Abuse And Neglect: Standard Health Citation — quality of care with minor potential harm and isolated scope found on March 6, 2026, not yet corrected.
ADL Care Provided For Dependent Residents: Standard Health Citation — quality of care with minor potential harm and isolated scope found on March 28, 2025, corrected May 9, 2025.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation — quality of care with minor potential harm and isolated scope found on March 28, 2025, corrected May 9, 2025.
Free Of Accident Hazards/supervision/devices: Standard Health Citation — quality of care with minor potential harm and isolated scope found on March 28, 2025, corrected May 9, 2025.
Infection Control: Standard Health Citation — quality of care with no harm potential and scope found on March 28, 2025, corrected May 9, 2025.
Label/store Drugs And Biologicals: Standard Health Citation — quality of care with minor potential harm and isolated scope found on March 28, 2025, corrected May 9, 2025.
License/comply W/ Fed/state/locl Law/prof Std: Standard Health Citation — quality of care with minor potential harm and isolated scope found on March 28, 2025, corrected May 9, 2025.
Nutritive Value/appear, Palatable/prefer Temp: Standard Health Citation — quality of care with minor potential harm and isolated scope found on March 28, 2025, corrected May 9, 2025.
Other Laws, Codes, Rules And Regulations.: Standard Health Citation — quality of care with no harm potential and scope found on March 28, 2025, corrected May 9, 2025.
Resident Bed: Standard Health Citation — quality of care with minor potential harm and widespread scope found on March 28, 2025, corrected May 9, 2025.
Treatment/service For Dementia: Standard Health Citation — quality of care with minor potential harm and isolated scope found on March 28, 2025, corrected May 9, 2025.
Building Construction Type And Height: Life Safety Code Citation — NFPA requirements with minor potential harm and isolated scope found on March 28, 2025, corrected May 16, 2025.
Cooking Facilities: Life Safety Code Citation — NFPA requirements with minor potential harm and isolated scope found on March 28, 2025, corrected May 16, 2025.
Electrical Equipment - Power Cords And Extens: Life Safety Code Citation — NFPA requirements with minor potential harm and isolated scope found on March 28, 2025, corrected May 16, 2025.
Electrical Systems - Essential Electric Syste: Life Safety Code Citation — NFPA requirements with minor potential harm and isolated scope found on March 28, 2025, corrected May 21, 2025.
Exit Signage: Life Safety Code Citation — NFPA requirements with minor potential harm and pattern scope found on March 28, 2025, corrected May 16, 2025.
Hazardous Areas - Enclosure: Life Safety Code Citation — NFPA requirements with minor potential harm and isolated scope found on March 28, 2025, corrected May 16, 2025.
Hvac: Life Safety Code Citation — NFPA requirements with minor potential harm and pattern scope found on March 28, 2025, corrected May 28, 2025.
Illumination Of Means Of Egress: Life Safety Code Citation — NFPA requirements with minor potential harm and isolated scope found on March 28, 2025, corrected May 16, 2025.
Interior Wall And Ceiling Finish: Life Safety Code Citation — NFPA requirements with minor potential harm and pattern scope found on March 28, 2025, corrected May 16, 2025.
Sprinkler System - Installation: Life Safety Code Citation — NFPA requirements with minor potential harm and isolated scope found on March 28, 2025, corrected May 23, 2025.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with minor potential harm and pattern scope found on March 28, 2025, corrected May 16, 2025.
Utilities - Gas And Electric: Life Safety Code Citation — NFPA requirements with minor potential harm and pattern scope found on March 28, 2025, corrected May 16, 2025.
ADL Care Provided For Dependent Residents: Standard Health Citation — quality of care with minor potential harm and isolated scope found on January 30, 2025, corrected March 25, 2025.
Request/refuse/dscntnue Trmnt;formlte Adv Dir: Standard Health Citation — quality of care with immediate jeopardy and isolated scope found on January 30, 2025, not yet corrected.
Free Of Accident Hazards/supervision/devices: Standard Health Citation — quality of care with minor potential harm and pattern scope found on December 29, 2023, corrected February 28, 2024.
Reporting - National Health Safety Network: Standard Health Citation — quality of care with minor potential harm and widespread scope found on November 20, 2023, not yet corrected.
ADL Care Provided For Dependent Residents: Standard Health Citation — quality of care with minor potential harm and isolated scope found on April 26, 2023, corrected May 26, 2023.
Assistive Devices - Eating Equipment/utensils: Standard Health Citation — quality of care with minor potential harm and isolated scope found on April 26, 2023, corrected May 26, 2023.
Dispose Garbage And Refuse Properly: Standard Health Citation — quality of care with minor potential harm and isolated scope found on April 26, 2023, corrected May 31, 2023.
Food In Form To Meet Individual Needs: Standard Health Citation — quality of care with minor potential harm and isolated scope found on April 26, 2023, corrected May 3, 2023.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation — quality of care with minor potential harm and pattern scope found on April 26, 2023, corrected June 26, 2023.
Increase/prevent Decrease In Rom/mobility: Standard Health Citation — quality of care with minor potential harm and isolated scope found on April 26, 2023, corrected May 26, 2023.
Infection Prevention & Control: Standard Health Citation — quality of care with minor potential harm and isolated scope found on April 26, 2023, corrected May 23, 2023.
Label/store Drugs And Biologicals: Standard Health Citation — quality of care with minor potential harm and isolated scope found on April 26, 2023, corrected May 26, 2023.
Medicaid/medicare Coverage/liability Notice: Standard Health Citation — quality of care with minor potential harm and isolated scope found on April 26, 2023, corrected May 23, 2023.
Nutritive Value/appear, Palatable/prefer Temp: Standard Health Citation — quality of care with minor potential harm and isolated scope found on April 26, 2023, corrected April 27, 2023.
Resident Self-admin Meds-clinically Approp: Standard Health Citation — quality of care with minor potential harm and isolated scope found on April 26, 2023, corrected May 23, 2023.
Responsibilities Of Providers; Required Notif: Standard Health Citation — quality of care with no harm potential and scope found on April 26, 2023, corrected April 27, 2023.
Right To Survey Results/advocate Agency Info: Standard Health Citation — quality of care with potential for minimal harm and widespread scope found on April 26, 2023, corrected April 27, 2023.
Safe/clean/comfortable/homelike Environment: Standard Health Citation — quality of care with minor potential harm and pattern scope found on April 26, 2023, corrected June 15, 2023.
Alcohol Based Hand Rub Dispenser (abhr): Life Safety Code Citation — NFPA requirements with minor potential harm and isolated scope found on April 26, 2023, corrected April 27, 2023.
Egress Doors: Life Safety Code Citation — NFPA requirements with minor potential harm and isolated scope found on April 26, 2023, corrected May 3, 2023.
Electrical Equipment - Testing And Maintenanc: Life Safety Code Citation — NFPA requirements with minor potential harm and widespread scope found on April 26, 2023, corrected June 22, 2023.
Elevators: Life Safety Code Citation — NFPA requirements with minor potential harm and isolated scope found on April 26, 2023, corrected May 1, 2023.
Exit Signage: Life Safety Code Citation — NFPA requirements with minor potential harm and isolated scope found on April 26, 2023, corrected May 24, 2023.
Fire Alarm System - Testing And Maintenance: Life Safety Code Citation — NFPA requirements with minor potential harm and widespread scope found on April 26, 2023, corrected May 2, 2023.
Hazardous Areas - Enclosure: Life Safety Code Citation — NFPA requirements with minor potential harm and isolated scope found on April 26, 2023, corrected May 18, 2023.
Illumination Of Means Of Egress: Life Safety Code Citation — NFPA requirements with minor potential harm and isolated scope found on April 26, 2023, corrected May 24, 2023.
Maintenance, Inspection & Testing - Doors: Life Safety Code Citation — NFPA requirements with minor potential harm and pattern scope found on April 26, 2023, corrected June 9, 2023.
Subdivision Of Building Spaces - Smoke Barrie: Life Safety Code Citation — NFPA requirements with minor potential harm and isolated scope found on April 26, 2023, corrected June 22, 2023.
Reporting - National Health Safety Network: Standard Health Citation — quality of care with minor potential harm and widespread scope found on June 27, 2022, not yet corrected.
Report Facts
Total inspections: 9
Total citations: 58
Standard Health citations: 32
Life Safety Code citations: 26
Total complaints: 180
On-site inspections from complaints: 17
Citations from complaints: 11
Enforcement actions: 3
Total fines: 14000
Inspection Report — Mar 28, 2025
Annual Inspection CMS
Date: Mar 28, 2025
Visit Reason
The survey was a recertification and abbreviated survey conducted from 3/24/2025 to 3/28/2025 to assess compliance with state and federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to provide adequate supervision and assistance with eating, inadequate supervision to prevent accidents, failure to implement telepsychiatry recommendations for dementia care, improper storage and labeling of controlled substances, serving food that was not palatable or at safe temperatures, improper food storage practices, failure to provide timely access to resident records and facility matrix, and failure to conduct regular inspections of bed frames, mattresses, and assist rails to prevent entrapment.
Citations (8)
F 0677: The facility failed to provide supervision and maximum cueing for eating and did not provide meals in the dining room as planned for Resident #142, resulting in poor nutrition.
F 0689: The facility failed to ensure adequate supervision to prevent accidents for Residents #164 and #171, including improper use of ice chips and failure to monitor wander alert devices.
F 0744: The facility did not implement telepsychiatry recommendations for non-pharmacological interventions for Resident #143 with dementia and behavioral symptoms.
F 0761: Controlled substances (lorazepam) were stored in unlocked refrigerators in Unit 1 North and Unit 3 medication rooms, violating storage requirements.
F 0804: The facility served food that was not palatable or at safe temperatures, including tough cube steak and improperly heated meals.
F 0812: Food in the main kitchen was stored improperly, including expired items, undated items, ice buildup on food boxes, and food stored on the floor.
F 0836: The facility failed to provide the facility matrix and timely access to all resident electronic health records as required during the survey.
F 0909: The facility failed to conduct regular inspections of bed frames, mattresses, and assist rails to identify entrapment hazards for multiple residents; mattresses were not securely placed and assist rails were not routinely inspected.
Report Facts
Meal consumption percentage: 26
Meal consumption percentage: 25
Meal temperature: 65.1
Meal temperature: 134.6
Meal temperature: 123.9
Meal temperature: 129.2
Meal temperature: 55.7
Food expiration date: Mar 20, 2024
Food expiration date: Mar 20, 2024
Food expiration date: Mar 3, 2024
Food expiration date: Dec 6, 2024
Food expiration date: Mar 13, 2024
Food expiration date: Dec 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #20 | Observed Resident #142's meal and stated uncertainty about proper food temperatures | |
| Food Service Director | Provided information on food temperature requirements and food storage policies | |
| Certified Nurse Aide #33 | Interviewed regarding Resident #142's meal assistance and Resident #143's behaviors | |
| Licensed Practical Nurse #34 | Interviewed regarding Resident #142's meal supervision and Resident #143's care plans | |
| Registered Nurse Unit Manager #19 | Interviewed regarding Resident #142's meal supervision and Resident #143's care plans | |
| Social Worker #37 | Interviewed regarding telepsychiatry recommendations and behavioral care plans for Resident #143 | |
| Licensed Practical Nurse #9 | Documented wandering incidents for Resident #164 and interviewed about bed mattress safety | |
| Licensed Practical Nurse #12 | Documented missing wander alert device meter and interviewed about Resident #164 wandering | |
| Maintenance Assistant #10 | Conducted entrapment zone testing for Resident #99's bed | |
| Registered Nurse Unit Manager #6 | Completed side rail/assist rail assessments and interviewed about mattress safety | |
| Certified Nurse Aide #44 | Observed Resident #15's mattress and assist rail use | |
| Licensed Practical Nurse #2 | Interviewed about mattress fit and assist rail safety for Resident #29 | |
| Registered Nurse Clinical Educator #1 | Interviewed about controlled substance storage and assist rail procedures | |
| Director of Nursing | Interviewed about survey access issues, assist rail policies, and maintenance practices | |
| Director of Maintenance | Interviewed about mattress safety and entrapment zone inspections |
Inspection Report — Jan 30, 2025
Abbreviated Survey CMS
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as an abbreviated survey to evaluate compliance with regulations related to resident care, including advance directives and assistance with activities of daily living.
Findings
The facility failed to properly document and communicate a resident's updated advance directive, resulting in inappropriate resuscitation efforts. Additionally, the facility did not ensure that a resident with feeding difficulties received the necessary assistance at meals as care planned.
Citations (2)
F 0578: The facility failed to establish mechanisms for documenting and communicating a resident's updated Advance Directives, resulting in initiation of cardiopulmonary resuscitation contrary to the resident's Do Not Resuscitate order. This posed immediate jeopardy to resident health or safety.
F 0677: The facility did not ensure that a resident with Alzheimer's disease and feeding difficulties received the required partial to moderate assistance at meals, impacting their nutrition and care.
Report Facts
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager #2 | Entered Do Not Resuscitate order and involved in updating Medical Orders for Life Sustaining Treatment | |
| Registered Nurse Supervisor #3 | Responded to unresponsive resident and initiated CPR based on outdated orders | |
| Licensed Practical Nurse #12 | Assisted in locating updated Medical Orders for Life Sustaining Treatment form | |
| Nurse Practitioner #5 | Signed updated Medical Orders for Life Sustaining Treatment form | |
| Director of Nursing/Administrator | Provided statements regarding system breakdown and corrective actions | |
| Certified Nurse Aide #1 | Observed during meal assistance failure for Resident #2 | |
| Certified Nurse Aide #2 | Observed during meal assistance failure for Resident #2 | |
| Registered Nurse Unit Manager #3 | Provided expectations for meal assistance compliance | |
| Director of Therapy | Provided information on level of assistance required for Resident #2 |
Inspection Report — Dec 29, 2023
Abbreviated Survey CMS
Date: Dec 29, 2023
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with regulations regarding supervision and prevention of accidents, specifically focusing on resident-to-resident incidents involving inappropriate sexual behaviors and physical aggression.
Findings
The facility failed to ensure adequate supervision to prevent accidents and inappropriate behaviors among residents with cognitive impairments. Multiple incidents of resident-to-resident sexual and physical aggression occurred without proper supervision or documentation of monitoring checks, despite care plans requiring 1:1 or 30-minute checks. Documentation gaps and inconsistent implementation of supervision were noted.
Citations (1)
F 0689: The facility did not ensure adequate supervision to prevent accidents and inappropriate sexual behaviors among residents with cognitive impairments, resulting in multiple incidents of resident-to-resident inappropriate contact and aggression without proper monitoring or documentation.
Report Facts
Residents involved in supervision incidents: 8
Dates of incidents: 2023
Duration of 1:1 supervision: 8
Frequency of monitoring checks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager #7 | Registered Nurse Unit Manager | Responsible for facility investigations, care plan updates, and supervision oversight. |
| Medical Director #12 | Attending Physician/Medical Director | Provided clinical oversight and discussed behavioral management strategies. |
| Certified Nurse Aide #4 | Witnessed incidents and provided statements regarding supervision practices. | |
| Certified Nurse Aide #5 | Provided 1:1 supervision and reported on resident behaviors and supervision gaps. |
Inspection Report — Apr 27, 2023
Abbreviated Survey CMS
Date: Apr 27, 2023
Visit Reason
The survey was conducted as a recertification and abbreviated survey to assess the facility's compliance with infection prevention and control requirements.
Findings
The facility failed to establish and maintain an effective infection prevention and control program, specifically during a wound treatment where a licensed practical nurse did not perform appropriate hand hygiene, risking potential infection to a resident's wound.
Citations (1)
F 0880: The facility failed to provide and implement an infection prevention and control program. Licensed practical nurse #5 did not perform appropriate hand hygiene during a wound treatment, using a dirty hand to apply a dressing which could introduce germs to the wound.
Report Facts
Residents Affected: 1
Deficiency citations: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #5 | Named in infection control deficiency for improper hand hygiene during wound treatment | |
| Infection Preventionist (IP) | Provided interview regarding expected infection control practices |
Inspection Report — Apr 27, 2023
Annual Inspection CMS
Date: Apr 27, 2023
Visit Reason
The survey was a recertification survey conducted from 4/19/23 to 4/27/23 to assess compliance with state and federal regulations for nursing home operations.
Findings
The facility had multiple deficiencies including failure to assess resident medication self-administration, failure to post survey results accessibly, failure to provide appropriate Medicaid/Medicare notices, environmental safety hazards, inadequate assistance with activities of daily living, improper application of range of motion devices, unlabeled medications, improper food temperature and consistency, lack of adaptive eating equipment, poor kitchen sanitation, improper disposal of fryer oil, and failure to follow infection control procedures during wound care.
Citations (13)
F554: The facility failed to assess and obtain physician orders for resident medication self-administration, resulting in unsafe medication practices for Resident #98.
F577: The facility failed to post the most recent Federal and Life Safety Code survey results in a location accessible to residents and representatives.
F582: The facility failed to provide appropriate Medicare liability and appeal notices to Resident #438 after Medicare Part A services ended.
F584: The facility failed to maintain a safe, clean, and homelike environment, with damaged ceilings, walls, windows, and unsealed penetrations on multiple floors.
F677: The facility failed to provide necessary assistance with activities of daily living including eating, grooming, and personal hygiene for Residents #108 and #109.
F688: The facility failed to ensure proper application and use of range of motion devices and positioning aids for Residents #66 and #93, including improper neck brace application and missing hand contracture devices.
F761: The facility failed to ensure medications, including insulin pens and eye drops, were labeled with resident information, medication name, dose, and administration instructions.
F804: The facility failed to ensure food was served at safe and palatable temperatures and the main kitchen steam table did not maintain proper hot food temperatures.
F805: The facility failed to provide food prepared in a form consistent with physician ordered diets for Residents #38 and #52, serving food that was not pureed as required.
F810: The facility failed to provide special eating equipment and utensils as care planned for Residents #30 and #38, including missing Kennedy cups, weighted utensils, and inner lip plates.
F812: The facility failed to store, prepare, and serve food in accordance with professional standards, including propped open tray line coolers with unsafe food temperatures, unclean kitchen equipment, damaged floors and ceilings, and rusty storage racks.
F814: The facility failed to properly dispose of waste fryer oil outside the main kitchen, resulting in spilled grease on the ground and a fire hazard.
F880: The facility failed to implement infection prevention and control practices during wound care for Resident #178, with licensed practical nurse #5 failing to perform appropriate hand hygiene between removing soiled dressing and applying clean dressing.
Report Facts
Residents affected: 1
Residents affected: 10
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 1
Temperature: 118
Temperature: 50
Temperature: 120
Temperature: 118
Temperature: 52
Temperature: 125
Temperature: 112
Temperature: 48
Temperature: 54
Temperature: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #10 | Licensed Practical Nurse | Named in medication self-administration and medication cart labeling findings |
| LPN #34 | Licensed Practical Nurse | Named in medication self-administration, ADL assistance, and diet consistency findings |
| RN Unit Manager #22 | Registered Nurse Unit Manager | Named in medication self-administration and contracture management findings |
| CNA #36 | Certified Nursing Assistant | Named in ADL assistance and diet consistency findings |
| Dietetic Technician #31 | Dietetic Technician | Named in food temperature and diet consistency findings |
| Food Service Director | Named in food temperature, kitchen sanitation, and fryer oil spill findings | |
| LPN #5 | Licensed Practical Nurse | Named in wound care hand hygiene deficiency |
| Infection Preventionist | Named in wound care hand hygiene deficiency |
Inspection Report — Oct 16, 2020
CMS
Date: Oct 16, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the survey.
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