Inspection Reports for
Elderwood at Waverly
37 North Chemung Street, Waverly, NY, 14892
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
175% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
40
30
20
10
0
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Mar 28, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey of the nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in providing adequate supervision and assistance with eating for residents unable to perform activities of daily living, ensuring accident prevention supervision, implementing telepsychiatry recommendations for dementia care, and serving food at appropriate temperatures and palatability.
Deficiencies (4)
F 0677: The facility failed to provide supervision and maximum cueing during meals for Resident #142, resulting in inadequate nutrition and failure to follow care plan instructions.
F 0689: The facility did not ensure adequate supervision to prevent accidents for Residents #164 and #171, including failure to follow aspiration precautions and monitor wander alert devices.
F 0744: The facility failed to implement telepsychiatry non-pharmacological recommendations for Resident #143 with dementia, resulting in inadequate behavioral management.
F 0804: The facility did not ensure food was palatable, attractive, and served at safe and appetizing temperatures, including tough cube steak and improperly tempered meals.
Report Facts
Meal consumption percentages: Resident #142 meal consumption ranged from 0-75% across multiple meals from 3/20/2025 to 3/27/2025.
Ice chips volume: 60
Food temperatures: 65.1
Food temperatures: 134.6
Food temperatures: 123.9
Food temperatures: 129.2
Food temperatures: 55.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #33 | Provided information about Resident #142's meal assistance and supervision needs. | |
| Licensed Practical Nurse #34 | Administered medications to Resident #142 and discussed supervision requirements. | |
| Registered Nurse Unit Manager #19 | Discussed care instructions and supervision expectations for Resident #142. | |
| Assistant Director of Therapy/Occupational Therapist #31 | Provided details on Resident #142's functional maintenance program and supervision needs. | |
| Certified Nurse Aide #25 | Reported providing ice chips to Resident #171 contrary to care instructions. | |
| Certified Nurse Aide #29 | Discussed Resident #171's diet and ice chip restrictions. | |
| Licensed Practical Nurse #30 | Documented Resident #171's barium swallow study and diet orders. | |
| Registered Nurse #14 | Discussed care instructions and supervision requirements for Resident #171. | |
| Licensed Practical Nurse #9 | Documented Resident #164's wandering behavior and redirection efforts. | |
| Licensed Practical Nurse Unit Manager #5 | Discussed wander alert device monitoring and supervision. | |
| Licensed Practical Nurse #12 | Documented missing wander alert device meter and wandering incidents. | |
| Social Worker #37 | Discussed telepsychiatry recommendations and behavioral care plans for Resident #143. | |
| Licensed Practical Nurse #20 | Tested food temperature and discussed food service practices. | |
| Food Service Director | Provided information on food temperature standards and meal quality. |
Inspection Report
Annual Inspection
Deficiencies: 8
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.
Deficiencies (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
Complaint Investigation
Capacity: 60
Deficiencies: 22
Date: Mar 28, 2025
Visit Reason
Multiple standard health and life safety code citations were issued, mostly level 2 severity, all corrected by May 2025.
Findings
Multiple standard health and life safety code citations were issued, mostly level 2 severity, all corrected by May 2025.
Deficiencies (22)
ADL care provided for dependent residents
Food procurement, store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Infection control
Label/store drugs and biologicals
License/comply w/ fed/state/locl law/prof std
Nutritive value/appear, palatable/prefer temp
Other laws, codes, rules and regulations.
Resident bed
Treatment/service for dementia
Building construction type and height
Cooking facilities
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Exit signage
Hazardous areas - enclosure
Hvac
Illumination of means of egress
Interior wall and ceiling finish
Sprinkler system - installation
Sprinkler system - maintenance and testing
Utilities - gas and electric
Inspection Report
Abbreviated Survey
Deficiencies: 2
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.
Deficiencies (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
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jan 30, 2025
Visit Reason
Two standard health citations issued including one immediate jeopardy for treatment refusal and advance directives; one corrected by March 2025, the other not corrected.
Findings
Two standard health citations issued including one immediate jeopardy for treatment refusal and advance directives; one corrected by March 2025, the other not corrected.
Deficiencies (2)
ADL care provided for dependent residents
Request/refuse/dscntnue trmnt;formlte adv dir
Inspection Report
Abbreviated Survey
Deficiencies: 1
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.
Deficiencies (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
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 29, 2023
Visit Reason
One standard health citation issued for accident hazards with a pattern scope, corrected by February 2024.
Findings
One standard health citation issued for accident hazards with a pattern scope, corrected by February 2024.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 20, 2023
Visit Reason
One standard health citation issued for reporting to national health safety network with widespread scope, not corrected.
Findings
One standard health citation issued for reporting to national health safety network with widespread scope, not corrected.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Abbreviated Survey
Deficiencies: 1
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.
Deficiencies (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
Annual Inspection
Deficiencies: 13
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.
Deficiencies (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
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jun 27, 2022
Visit Reason
One standard health citation issued for reporting to national health safety network with widespread scope, not corrected.
Findings
One standard health citation issued for reporting to national health safety network with widespread scope, not corrected.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Deficiencies: 0
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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