Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elderwood At Cheektowaga during CMS and state inspections, most recent first.
A resident with severe cognitive and neurologic impairment had repeated witnessed and unwitnessed falls despite multiple documented fall-risk interventions, and the care plan was not consistently reassessed or updated after each incident. The resident sustained multiple injuries, including a wrist fracture, rib fractures, an elbow fracture, abrasions, bruising, and a head injury requiring hospitalization. Staff interviews showed ongoing self-transfers, poor safety awareness, and attempts to provide close observation, while two other residents were also observed smoking unsafely near the facility, including improper cigarette disposal and no smoking care plan for one resident.
Unsafe and Unclean Resident Environment: Surveyors found a resident bathroom with damaged drywall, dirty flooring, and deteriorated caulk, along with multiple bathing suites showing clogged drains, missing or damaged tiles, loose grab bars, soiled shower curtains, chipped paint, dead flies, and a dark shower room due to a light outage. Hallway carpets throughout the facility were heavily discolored, stained, and malodorous, and residents, family members, and staff described the environment as filthy, smelly, and not homelike.
The facility did not maintain enough nursing staff to meet its staffing plan or resident needs. Staffing sheets showed multiple shifts below the facility’s minimum CNA levels, and staff reported that when only two or three CNAs were on a unit, assignments were heavy and some nurses did not fully assist as aides. Residents reported long waits for call lights, delayed toileting and brief changes, missed or delayed showers, and being left in bed or soiled for extended periods. Resident council minutes also documented short staffing, unanswered call bells, and staff leaving before shifts ended.
Surveyors found active wastewater discharge and a sewage-like odor in the kitchen dishwashing area, with staff reporting repeated drain backups and a contractor identifying grease, straws, and plastic blocking the sewer line. Surveyors also observed water pooling in one walk-in refrigeration unit and heavy ice buildup in two walk-in freezer units, including around fans, tubing, an actively leaking pipe, and a sprinkler head deflector.
Failure to Administer Facility Operations to Ensure Resident Safety: The Administrator was not aware that care plan interventions were not updated for a resident and expected unit managers to handle care plan updates. The facility also did not consistently monitor smoking concerns, and leadership stated there should not have been any smokers at the facility. Interviews showed the Administrator was expected to keep residents safe, but oversight of care planning and smoking policy implementation was inconsistent.
QAPI Failure to Address Falls and Smoking Safety Deficiencies: The facility’s QAPI process did not effectively address resident safety issues. A resident with progressive neurodegenerative disease, orthostatic hypotension, and repeated falls had multiple unwitnessed and witnessed falls with injuries including fractures and a head injury, yet the falls and safety interventions were not re-evaluated in the care planning process. Two residents were also observed smoking without adequate supervision or clear follow-up; one resident with CVA, aphasia, epilepsy, and impaired cognition smoked in the courtyard without staff present, and another cognitively intact resident smoked in a patio area near the building despite the facility being smoke free.
Failure to establish a smoking policy for resident smokers: the facility said it was smoke free and had no smoking policy for current smokers, despite having two residents who smoked and a policy that allowed an outdoor smoking area and grandfathered privileges for certain residents. One resident with CVA, aphasia, epilepsy, and impaired cognition was observed smoking in the courtyard/patio area and placing the cigarette butt in a shoe, while another resident with cerebrovascular disease, MDD, and HTN was observed smoking about 13 feet from the building and extinguishing the cigarette on a wheelchair wheel.
A resident with hemiplegia and another resident with cerebrovascular disease and depression did not have their documented preferences honored. One resident’s care plan called for showers twice weekly, but the shower schedule, Kardex, and actual shower documentation reflected only weekly showers, and staff said bathing was assigned by room number. The other resident’s care plan listed a 7:00 AM rise time and dining room meals, but observations and interviews showed the resident was often left in bed past that time and ate in bed, with staff citing staffing limitations and inconsistent use of the dining room.
A resident with severe cognitive impairment, aphasia, and dysphagia was dependent on staff for showers, but surveyors found no documentation that the resident received scheduled bathing. The resident was repeatedly observed with greasy, disheveled hair, and an LPN, CNA, unit manager, and interim DON all acknowledged that a blank care tracker meant there was no way to verify the shower occurred.
Poor communication during a resident’s admission led to delayed nursing assessment and delayed recognition that the resident’s O2 tank was empty. The resident arrived with O2 by nasal cannula, but the nursing supervisor was unaware the resident was on the unit, and staff did not complete the admission process promptly. Hours later, the responsible party reported pain and SOB; an LPN found the O2 sat at 58% with the tank in the red, replaced the tank, and the resident’s saturation improved. The resident had recent acute respiratory failure with hypercapnia from COVID-19 and MRSA pneumonia, along with dyspnea and other serious medical conditions.
Delayed Pain Medication Administration: A resident with MS, chronic pain syndrome, and paraplegia requested PRN Norco from a CNA, but the request was not passed to the LPN right away. The resident remained in bed waiting for the medication and did not receive it until later, when pain was documented at 7/10. Interviews showed the CNA waited for another LPN to come on duty even though an LPN was already on the unit, and the LPN stated timely pain medication is important to prevent pain from worsening.
The facility failed to complete annual CNA performance reviews for three of five CNAs reviewed. Records showed one CNA had no annual competency in the prior year, another had no evidence of any annual competency, and a third had not had an annual competency since the prior year. The Administrator said the educator was responsible for the reviews, but no annual staff competencies were completed that year, and the educator stated the evaluations were done informally and could not confirm every staff member was reviewed.
A medication cart on a unit was left unlocked and unattended while an RN entered a resident’s room, and the EMR screen displayed that resident’s PHI in plain view of residents, staff, and visitors. Surveyors also found opened multidose vials in the med refrigerator that were not properly dated or discarded after the 28-day limit, including PPD and Humalog insulin.
A resident with cognitive intactness, malnutrition, and prediabetes had a diet order for regular, no pork, regular texture, and thin liquids, but received a breakfast tray with bacon. The resident reported the first tray contained pork and staff had to replace it; dietary staff prepared trays without referencing individual meal tickets, while the RD was aware of the resident’s religious no-pork preference.
Failure to use required PPE during enhanced barrier precautions: staff did not wear gowns during hands-on care for two residents who had wounds and, in one case, an indwelling catheter. A CNA transferred one resident without a gown, and an LPN performed wound care on another resident without a gown while handling drainage. Both residents were on enhanced barrier precautions, and facility leaders stated gowns and gloves were expected for these care activities.
CNAs did not receive the required annual in-service education. Two CNAs reviewed had only partial training hours recorded, and interviews showed the educator role changed during the year, with a gap in staffing and inconsistent monitoring of LMS training completion. One CNA knew the annual 12-hour requirement, while another was unaware of it and reported that education was not offered consistently.
Failure to designate a qualified Infection Preventionist: The facility identified the ADON as the IP, but survey findings showed the ADON had not completed the required specialized IP training/certification when the role was assigned. The Administrator also referenced a Regional Nurse Consultant and a CNO from an ALF, but neither was employed part-time or full-time at the facility and neither was acting as the IP. Training records showed the ADON completed most of the IP modules only during the survey period, and the Administrator stated the training should have been completed within the 30-day timeframe.
Failure to complete required registry screening before hire was cited after the facility allowed a CNA, an activity leader, and a housekeeping aide to work before their NY State Nurse Aide Registry verifications were completed. The facility’s policy required pre-hire screening for abuse, neglect, exploitation, and misappropriation history, but records showed each employee worked shifts before the registry check date.
Carbon monoxide alarms throughout the facility were found with visible dust buildup on the covers, including Model A and Model B plug-in battery backup units in resident unit corridors and Model C battery-operated alarms in the kitchen area. The Maintenance Supervisor stated the alarms were tested monthly but were not being cleaned, and the manufacturers' instructions called for regular or monthly vacuuming to remove dust.
The facility failed to ensure residents were properly educated about the COVID-19 vaccine and that their consent or declination was accurately documented. One cognitively intact resident with multiple chronic conditions was recorded as having declined the COVID-19 vaccine without a signed or verbally documented declination and without any documented education on risks and benefits; in interview, this resident stated they wanted the vaccine and had never received education or signed a declination. Review of vaccination forms for 34 other residents who were marked as having declined the COVID-19 vaccine showed no signed declinations and no documentation that Vaccine Information Sheets or other education were provided. Staff and leadership interviews confirmed that education on risks/benefits and completion of consent/declination sections with signatures or verbal documentation were expected but were not carried out or recorded as required.
Two residents with dementia and documented cognitive impairment received COVID-19 and influenza vaccines based on verbal consents obtained directly from them by the Assistant DON/Infection Preventionist, despite activated Health Care Proxies and prior documentation that they lacked medical decision-making capacity. Facility policies and state and federal resident rights documents required informed consent and recognized the authority of health care agents when residents lack capacity. In both cases, the health care agents were not contacted for consent, were unaware the vaccines had been administered, and later stated they would have expected to be involved in these decisions, demonstrating a failure to honor residents’ rights to refuse treatment and to obtain consent from the appropriate representatives.
Three residents with cognitive and chronic medical conditions received influenza and/or COVID-19 vaccines from an outside pharmacist during a vaccine clinic, but the facility’s MAR and immunization records inaccurately documented that facility nurses administered these vaccines or left the administrator information incomplete. Facility policy required that immunizations be documented by the nurse who administered them and that vaccines given by non-facility staff be entered as outside-agency or historical immunizations in the EMR, rather than as standard MAR entries. An LPN reported signing the MAR for vaccines they did not administer, based on verification forms and resident reports, while another LPN stated they only entered orders and did not give any vaccines, despite being listed as the administering nurse. Leadership and nursing staff acknowledged that nurses should not document medications they did not administer or witness, yet the records continued to reflect inaccurate or incomplete documentation of who actually gave the vaccines.
A resident with an indwelling Foley catheter and a history of UTIs was repeatedly observed with the drainage bag positioned above bladder level and not wearing a leg bag as care planned. There were no provider orders for the catheter or its care, and the care plan contained outdated and inaccurate information about the resident's urinary devices. Staff interviews revealed lapses in updating care plans, obtaining orders, and following proper catheter care procedures.
A certified nurse aide was found to have verbally abused a resident by yelling and making inappropriate comments during care, as witnessed by another resident and confirmed by staff interviews. The resident, who was cognitively intact and had multiple medical conditions, reported feeling hurt and disappointed by the aide's actions. The incident was corroborated by witness statements and staff, who recognized the behavior as verbal and mental abuse.
A facility failed to ensure a Consultant Pharmacist reported irregularities in a resident's drug regimen review, leading to the prolonged use of an antibiotic without an end date. The resident, with severe cognitive impairment and multiple diagnoses, was prescribed Doxycycline Monohydrate since 2020. The pharmacist did not identify or report the excessive duration, and the DON was unaware of the antibiotic use. The deficiency was noted during a standard survey, indicating a lapse in medication management and antibiotic stewardship.
A resident with severe cognitive impairment and multiple diagnoses, including MRSA, was receiving Doxycycline Monohydrate for lifelong suppression without proper monitoring by the facility's Infection Preventionist or Antibiotic Stewardship Program. The facility's policy required tracking and reporting of antibiotic usage, but this was not done. Staff interviews revealed a lack of awareness and monitoring due to the antibiotic not appearing on the facility's dashboard, and there was no process to review the pharmacy's report.
A facility failed to review and renew a resident's Medical Orders for Life-Sustaining Treatment (MOLST) as required, leading to a discrepancy between the resident's current wishes and documented orders. Despite the resident's moderate cognitive impairment and history of serious medical conditions, their MOLST form had not been updated since a specified date. Interviews with staff revealed a lack of consistent review, highlighting the importance of aligning medical orders with residents' current wishes.
The facility failed to properly label and manage medications in the Unit 4 storage room. Observations revealed undated and outdated Tubersol vials and expired over-the-counter medications. Staff interviews highlighted lapses in adherence to labeling and expiration protocols, with responsibilities shared among LPNs, the Pharmacy Technician, and the Shipping/Receiving Manager. The DON and Administrator emphasized the need for proper labeling and removal of expired medications.
A facility failed to notify a resident and their family of a room change and a positive COVID-19 test. The resident's room was changed without notification, and the family was unaware of the COVID-19 diagnosis until visiting. Staff interviews confirmed the lack of documentation and communication.
A resident with cognitive impairments and dependent on staff for toileting was left exposed during incontinent care by a CNA, compromising their privacy and dignity. Despite the facility's policies on respecting residents' rights, the CNA left the resident uncovered and visible to the hallway, and staff interviews confirmed the lapse in maintaining privacy.
A resident with dementia and hemiparesis experienced a delay in receiving a lumbar x-ray after a fall, due to communication and documentation failures. Although x-rays for the elbow and sacral regions were completed, the lumbar x-ray was delayed because the order was not entered into the electronic medical record, and the Unit Clerk was not informed through the usual process. Staff interviews highlighted inconsistencies in the ordering and documentation process, leading to the deficiency.
Failure to Prevent Recurrent Falls and Unsafe Resident Supervision
Penalty
Summary
The facility failed to ensure that residents’ environments remained as free of accident hazards as possible and that residents received adequate supervision to prevent accidents. The deficiency involved three residents, including one resident with progressive supranuclear ophthalmoplegia, orthostatic hypotension, severely impaired cognition, poor safety awareness, and a long history of recurrent falls. The resident’s assessments and care plan identified multiple fall risks and listed numerous interventions, including supervision, scheduled toileting, safety checks, and environmental precautions. Despite these documented interventions, the resident experienced frequent witnessed and unwitnessed falls over several months, with repeated incident reports showing no documented changes to the care plan after many of the falls. The reports repeatedly noted that the collaborative care plan remained effective and appropriate, but did not document revisions or evaluation of whether the interventions were working. The resident sustained multiple injuries from these falls, including bruising, abrasions, cuts, a left wrist fracture, a non-displaced acute fracture of the lateral humeral condyle, fractures of the left 11th and 12th ribs, an avulsed component of the lateral humeral condyle, and a head injury with lethargy and changes in mentation that resulted in hospitalization. The record also showed that staff recognized the resident’s falls were ongoing and that interventions were not effective, yet the care plan was not consistently updated. Interviews with nursing staff, therapy staff, the DON, the Administrator, and the physician reflected that the resident continued to self-transfer, stand, and fall despite repeated incidents and injuries. Staff described trying various measures, including sitting near the resident and discussing falls in morning report, but the documentation did not show consistent reassessment or care plan revision after each fall episode. In addition, two other residents were observed engaging in unsafe smoking practices, including smoking too close to the facility, improper extinguishing of cigarettes, and disposal of cigarette butts in garbage cans, and one of those residents had no documented smoking care plan.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior across four resident units. Surveyors observed Resident #155’s bathroom with damaged drywall near the mirror, dirty flooring around the toilet and room perimeter, discolored baseboards, and cracking caulk around the toilet base. The resident stated the damaged wall looked filthy and was not very sanitary, and said the issue had been complained about previously but never fixed. The Environmental Services Manager later observed the bathroom and stated the area needed more cleaning, the baseboards needed replacement, and the drywall needed to be patched. The Director of Plant Operations also observed the damaged wall and stated staff should have notified maintenance so it could be fixed, and that it was not homelike. Surveyors also observed multiple bathing suites with damaged and soiled conditions. In one suite, there was a dust-laden wall and vent, soiled shower curtain corners, a cracked tub lift seat, chipped paint, and scrape marks on the restroom door. In another, the shower drain was clogged with hair and a plastic wrapper, one shower curtain liner was frayed, dead flies were present in the closet, the restroom door had chipped paint and scrape marks, and the ceiling tile above the toilet was damaged. In a third suite, the shower floor was missing a tile section, and in another, the fluorescent light was not working, leaving the room completely dark while the floor was wet and steam was present; the grab bar was loose, the shower curtain was soiled, and chipped paint was present on the door. Additional observations showed deteriorated caulk, missing shower tiles, soiled grout, damaged wall areas around a grab bar, and damaged doorframe/baseboard areas in another bathing suite. Staff interviews showed inconsistent understanding of responsibility for reporting and correcting these issues, and the Director of Plant Operations stated there were no TELS requests for bathing suites except one damaged ceiling tile. The facility also failed to maintain resident-use corridors in a clean and comfortable condition. Surveyors observed widespread carpet discoloration throughout hallways on multiple units, including large dark stains, streaks, thick food debris, and areas with a malleable texture. Residents, family members, housekeeping staff, and therapy staff described the carpets as filthy, smelly, dingy, and associated with urine odors. The Environmental Services Manager stated the carpeting was old and needed replacement, and the Administrator acknowledged the smells and stains and stated the condition did not create a homelike environment for residents. The report cited 10 NYCRR 415.5(h)(1)(2).
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and to maintain the minimum staffing levels described in its facility assessment and staffing plan. The report states the facility had 172 licensed beds, an average daily census of 150, and a direct care nursing staffing plan dated 07/01/2025 that called for five CNAs per unit on day shift, four per unit on evening shift, and two per unit on night shift based on an anticipated census of 162. During interview, the Administrator stated the facility’s minimum staffing numbers were three CNAs per unit on day and evening shifts and one per unit on night shift, with staffing adjusted based on census. The Administrator also stated that if only two CNAs were on an evening shift, staff would be floated from another unit or therapy staff would be asked to work as aides, and that nurses could drop down and work as aides. Review of staffing sheets showed the facility did not meet its stated minimum CNA staffing on multiple shifts. On one evening shift there were 11 CNAs until 6:00 PM and nine after 6:00 PM; on one day shift there were 10 CNAs until 11:00 AM with notes that staff were late or left early; on one evening shift there were six CNAs plus one nurse working as an aide and another nurse working as an aide until 7:00 PM; and on another evening shift there were nine CNAs including one nurse working as an aide. Interviews with staff confirmed that there were times when only two or three CNAs were available on a unit, that assignments were heavy, and that nurses did not always help or take a full aide assignment. One LPN stated that on one morning the scheduled CNAs had not arrived and she was the only staff member on the unit at that time. Residents and resident representatives described delayed responses to call lights, delayed toileting, delayed showers, and being left in bed or soiled for extended periods. One resident stated call bells could take 20 to 30 minutes to be answered, another reported waiting 45 minutes for brief changes, and another said they waited 30 minutes to hours for call bell response and had been left incontinent and soiled for hours. A resident representative reported that a family member could not get scheduled Sunday showers because there were only two CNAs. Resident Council minutes also documented short staffing, unanswered call bells, staff leaving before the end of shifts, and aides turning off call lights without returning. Staff interviews echoed these concerns, stating that when staffing was low, residents who needed feeding or behavior support were prioritized and there was not enough time to get residents up at preferred times, complete showers, or finish charting.
Kitchen Drain Backup and Walk-In Freezer/Ice Accumulation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Surveyors observed active wastewater discharge in the main kitchen dishwashing area, and the kitchen had a malodorous sewage-like smell during the observation. The report also documented that the kitchen sewer line had backed up and required contractor intervention, with the contractor finding food grease, straws, and plastic blocking the line and advising caution with items sent down kitchen drains. The kitchen drainage problem was not isolated. Facility staff stated the drains in both the kitchen dishwash area and the dishwashing room had backed up, and the Maintenance Director described the disposal issues as ongoing and occurring on a near-monthly basis. The Administrator stated they were not aware of the waste disposal situation or the ongoing backups, while the Director of Plant Operations stated dietary staff had been told many times not to put grease and plastic wrap down the drain. Surveyors also observed environmental conditions in the food storage units that were not maintained in proper condition. One walk-in refrigeration unit had water pooled on the floor, and two walk-in freezer units had significant ice accumulation on interior walls, ceilings, floors, behind fans and tubing, and around an actively leaking pipe. One freezer also had icicles on a sprinkler head deflector. The Food Service Director stated the ice buildup occurred when a freezer door was left open during delivery, and the Maintenance Director stated the contractor had been onsite to assess the freezer units and planned repairs, while the facility did not maintain documentation of prior HVAC work.
Failure to Administer Facility Operations to Ensure Resident Safety
Penalty
Summary
The facility was not administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The deficiency was based on interview and record review during an extended standard survey completed on 04/23/2026, which found that the administration did not ensure residents were free of accident hazards, did not ensure adequate supervision, and did not consistently implement and monitor facility policies and protocols for effectiveness. The facility policy titled Resident Care Standards dated 10/22/2018 stated the Administrator was responsible for maintaining resident care standards, providing a safe environment, and monitoring care through review of accident and incident reports, care planning meetings, family contact, communication with consultants and professional staff, monthly reports, and daily or scheduled rounds. During an interview on 04/21/2026, the Administrator stated they were not aware that care plan interventions were not updated for Resident #87 and expected unit managers to update care plans. The Administrator also stated they did not think anything was wrong with the interventions in place. During later interviews, the Administrator acknowledged the facility could have done a better job auditing and following up with smokers to ensure they were safe and not smoking close to the building. The Regional Nurse Consultant stated there was only a non-smoking policy and it did not apply to current smokers at the facility, that there should not have been any smokers at the facility, and that smoking concerns should have been directed to the Administrator. The Chief Operating Officer stated the Administrator was expected to keep residents safe and ensure smoking did not occur.
QAPI Failure to Address Falls and Smoking Safety Deficiencies
Penalty
Summary
The facility failed to ensure its QAPI program effectively developed and implemented plans of action to correct identified quality deficiencies related to resident safety. The report states the facility had a QAPI policy dated 03/18/2025 that described a data-driven program intended to use systematic analysis, corrective actions, and tracking to sustain improvements, but survey findings showed those processes were not effectively used for the issues identified during the survey. Resident #87, who had progressive supranuclear ophthalmoplegia, orthostatic hypotension, and repeated falls, experienced frequent witnessed and unwitnessed falls from 12/03/2025 through 04/20/2026. The facility did not adequately assess, implement, or evaluate safety interventions after the repeated falls. The resident sustained multiple injuries, including bruising, cuts, abrasions, pain, a left wrist fracture, a nondisplaced acute fracture of the lateral humeral condyle, fractures of the left 11th and 12th ribs, an avulsed component of the lateral humeral condyle, and a head injury with lethargy and changes in mentation that resulted in hospital admission. Documentation showed a quality of life review on 01/14/2026 and a care plan meeting on 01/27/2026, but there was no documentation that the resident's frequent falls or safety interventions were re-evaluated or discussed. The report also identified smoking supervision concerns involving Resident #116 and Resident #30. Resident #116 had diagnoses including cerebral infarction, aphasia, and epilepsy, and was documented as having moderately impaired cognition; during observations, the resident smoked outside without staff present, including in the courtyard next to the building, and placed a cigarette butt in a shoe. Resident #30, who was cognitively intact, had no smoking-related care plan and was observed smoking in a patio area near the building and extinguishing cigarettes on a wheelchair wheel before disposing of the butt in a garbage can. Interviews with the DON, Administrator, Regional Nurse Consultant, and COO confirmed residents were smoking in areas where they were not supposed to smoke and that supervision and follow-up were lacking.
Failure to Establish Smoking Policy for Resident Smokers
Penalty
Summary
The facility failed to establish smoking policies in accordance with applicable Federal, State, and local laws regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents. The facility policy titled Smoke Free Environment stated smoking was prohibited inside the facility, allowed a separate outdoor smoking area on the ground at least 30 feet from facility structures, and noted the Administrator could grandfather residents admitted prior to October 8, 2013 for supervised or unsupervised smoking privileges. However, the Administrator stated during the entrance conference and again later that the facility was considered smoke free and there was no smoking policy because it was a non-smoking facility, and the Regional Nurse Consultant stated there was only a non-smoking policy and it did not apply to current smokers at the facility. A facility-provided list identified two residents as smokers and listed the smoking location as a bench near the front entrance to the main campus. Resident #116 had diagnoses including cerebral infarction, aphasia, and epilepsy, and MDS documentation noted tobacco use and moderately impaired cognition. During observation, this resident was smoking in the courtyard/patio area next to the building, put the cigarette out, placed the butt in their shoe, and left the area. Resident #30 had diagnoses including cerebrovascular disease, major depressive disorder, and hypertension, and MDS documentation noted the resident was usually understood, usually understands, and was cognitively intact. During observation, this resident was about 13 feet from the building in a patio/courtyard area, lit and smoked a cigarette, extinguished it on the wheel of the wheelchair, and discarded the butt in a garbage can.
Resident Preferences for Bathing, Rise Time, and Dining Were Not Followed
Penalty
Summary
The facility did not ensure residents were able to choose activities, schedules, and health care consistent with their interests, assessments, and plan of care for two residents reviewed for choices. One resident, who had hemiplegia, weakness, hypertension, and was cognitively intact, had a care plan and preference for bathing two times weekly, but the shower schedule, Kardex, and unit shower process reflected only one weekly shower. Survey observations, interviews, and record review showed the resident’s last documented scheduled shower was completed weeks earlier, with no further documented evidence that the resident received showers twice weekly as planned. Staff interviews showed showers were assigned by room number and that there was no specific process for asking how many showers the resident preferred. The same resident stated showers were scheduled for Thursdays and that they had told the unit manager they preferred two showers weekly, but were lucky to receive one shower per week when staff could fit them in. Staff also stated the resident’s shower frequency had been changed back to once weekly, but they did not know why. The unit manager and other leadership staff acknowledged that the Kardex, care plan, and shower schedule should match and that resident preferences should be honored, but the documented schedule and actual shower completion did not reflect the resident’s stated preference for twice-weekly showers. A second resident, who had cerebrovascular disease, major depressive disorder, hypertension, and was cognitively intact, had a care plan documenting a rise time preference of 7:00 AM and a preferred dining location in the unit dining room for meals. Record review showed no documented evidence that the resident refused morning care or chose to remain in bed. However, interviews and observations showed the resident was repeatedly left in bed past the preferred rise time and ate in bed rather than in the dining room. The resident stated they wanted to get up in the morning and that staff sometimes left them in bed until after 11:00 AM because of staffing. Staff interviews confirmed that getting residents up and using the dining room often depended on staffing, and one CNA stated they were not aware of the resident’s documented 7:00 AM preference even though it should have been followed.
Failure to Document and Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a dependent resident received the necessary assistance with activities of daily living to maintain good grooming and personal hygiene. Resident #102, who had diagnoses including vascular dementia without behavioral disturbances, aphasia, and dysphagia, was assessed as severely cognitively impaired and dependent on staff for showers. The resident’s care plan identified a bathing schedule of Wednesday day shift, and the facility’s hygiene and grooming policy required residents to be kept clean and appropriately groomed, with scheduled baths/showers documented in the computerized point of care system. Surveyors found no documented evidence that Resident #102 received the scheduled showers on 04/01/2026, 04/08/2026, 04/15/2026, or 04/22/2026. During multiple observations, the resident was seen with greasy, disheveled or slicked-back hair. Staff interviews confirmed the lack of documentation and inability to verify that the showers occurred; an LPN, a CNA assigned to the resident, the unit manager, and the interim DON all stated that if the care tracker was blank, there was no way to prove the shower was given, and the CNA and LPN could not recall whether the resident had received the shower.
Delayed Admission Assessment and Oxygen Care Due to Poor Communication
Penalty
Summary
The facility did not ensure that Resident #162 received treatment and care in accordance with orders, resident preferences and goals, and the comprehensive care plan because staff communication broke down during the resident’s admission. Resident #162 was admitted with diagnoses including iron deficiency anemia secondary to blood loss, adult failure to thrive, dyspnea, and a recent history of acute respiratory failure with hypercapnia due to COVID-19 and MRSA pneumonia. The resident’s MDS documented cognitive intactness and oxygen therapy use while in the facility. Resident #162 arrived by stretcher with oxygen via nasal cannula from a mini transport tank and was placed in bed by paramedics and CNAs. The admission paperwork was received by the receptionist, but the nursing supervisor on duty was not aware the resident had arrived, and the admission process was not started in a timely manner. Staff interviews and the facility’s own investigation showed that the receptionist, nursing supervisor, unit manager, and nursing staff did not have a clear handoff or awareness that the resident was on the unit, and the admission assessment was delayed. Several hours after arrival, the resident’s responsible party reported pain and difficulty breathing. An LPN found the oxygen tank in the red/empty, with the resident’s oxygen saturation at 58%. After a new oxygen tank was applied, the saturation increased to 90%. The resident was later assessed as lying supine with eyes closed, chest heaving, labored respirations, tachypnea, and bluish-purple fingertips. The responsible party and staff stated there was a large lack of communication, and the interim DON stated there was poor communication and that the admission assessment should have been completed within an hour of arrival.
Delayed Pain Medication Administration
Penalty
Summary
The facility failed to provide timely pain management for Resident #69, who had diagnoses including multiple sclerosis, chronic pain syndrome, and paraplegia. The resident’s Minimum Data Set documented intact cognition and a scheduled plus PRN pain medication regimen for frequent severe pain that frequently interfered with day-to-day activities. The comprehensive care plan directed staff to assess pain characteristics, reassess and adjust the plan as needed, and teach the resident to request analgesics before pain became severe. On 04/17/2026, Resident #69 told CNA #22 at about 2:15 PM that they wanted their Norco pain pill, but the medication was not given at that time. During an observation and interview at 2:56 PM, the resident was lying in bed and stated they had asked for the pain pill but had not received it yet. The medication administration record showed the hydrocodone-acetaminophen 10-325 mg tablet was administered at 3:45 PM, and the resident’s pain level at that time was documented as 7/10. During interviews, CNA #22 stated they waited to tell the oncoming LPN about the resident’s request until 3:00 PM, even though an LPN was already on the unit. The LPN stated they had been working on the unit since 7:00 AM and did not know why the request had been delayed. The LPN also stated it was important to give pain medication in a timely manner to prevent pain from getting worse and to stop the resident from being in pain. CNA #22 stated residents should receive pain medication shortly after requesting it and acknowledged they probably got busy and did not tell the LPN sooner.
Missing Annual CNA Competency Reviews
Penalty
Summary
The facility failed to ensure Certified Nurse Aide performance reviews were completed at least once every 12 months for three of five CNAs reviewed: CNA #3, CNA #9, and CNA #10. Record review showed CNA #3’s last annual competency skills evaluation was on 08/28/2024 with no documented annual competency in 2025, CNA #9 had no evidence of an annual competency skills evaluation, and CNA #10’s most recent annual competency skills evaluation was on 06/26/2024 with no documented annual competency in 2025. The facility policy stated that annual mandatory training and job performance review expectations were the responsibility of administration and evaluating managers. During interviews, the Administrator stated Educator #1 was the educator in 2025 and that no annual staff competencies were completed that year. The Administrator said they relied on Educator #1 to complete them and did not review whether they were done. CNA #9 stated they had worked at the facility since 2009 and did not remember having an annual evaluation completed in 2025, adding that the facility had not had a steady staff educator for a while. Educator #1 stated annual evaluations were done informally, that documentation would exist if they were completed, and that they could not say every staff member’s evaluation had been done. The former DON could not be reached for interview.
Unsecured medication cart and improperly labeled opened medications
Penalty
Summary
The facility failed to maintain drugs and biologicals labeled in accordance with accepted professional principles and to keep medications stored securely. During observation on Unit 4 South, the medication cart was left unlocked and unattended or not within direct view of authorized staff while RN #6 went into Resident #75’s room to obtain vital signs. Resident #75 had diagnoses including end stage renal disease, diabetes mellitus, and hypertension, and the MDS documented the resident was cognitively intact and able to understand and be understood by others. At the same time, the electronic medical record screen on the cart displayed Resident #75’s personal medical information in plain view in an area accessible to residents, staff, and visitors, and an unidentified resident and visitors were in the vicinity. The Unit 4 medication refrigerator also contained medication storage issues. Surveyors found one opened multidose vial of Tuberculin Purified Protein Derivative solution with an opened date on the box and one opened bottle of Humalog insulin without an opened date. Both pharmacy labels directed that the medications be discarded after 28 days of opening, but the insulin was not dated and the tuberculin vial had not been discarded as required. Staff interviews confirmed the cart should have been locked or kept in view, the screen should have been secured, and opened medications should have been dated and discarded according to the 28-day requirement.
Failure to Honor Resident's No-Pork Religious Food Preference
Penalty
Summary
The facility failed to ensure that a resident received food that accommodated the resident’s religious food preference of no pork. Resident #164 had diagnoses including syncope and collapse, unspecified severe protein-calorie malnutrition, and prediabetes, and the Minimum Data Set documented the resident was cognitively intact and required setup or clean-up assistance with eating. The care plan identified an alteration/potential for alteration in nutrition and included interventions to determine dietary preferences and offer substitutes as needed. The resident’s diet order and Kardex both documented regular diet, no pork, regular texture, and thin liquids, and progress notes stated the resident avoided pork due to religion and that pork was added as a dislike in the menu system. During breakfast observation, the resident’s tray ticket listed no pork among the dislikes, but the resident stated the first tray came with bacon and staff had to swap it. The resident then received a second tray, but stated the pancakes appeared unappetizing and did not eat anything from it. A CNA stated they returned to the kitchen to get another breakfast tray after the resident reported pork on the first tray. The Food Service Director stated dietary staff made trays in the kitchen using a numeric breakdown of tray types and did not reference individual meal tickets when preparing trays, while nursing staff read the meal tickets when obtaining trays for delivery. The Registered Dietitian stated they were aware of the resident’s religious preference of no pork and that honoring religious preferences was part of resident rights and resident choice.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain its infection prevention and control program by not ensuring enhanced barrier precautions were followed for two residents who were at increased risk for MDRO acquisition because of wounds and indwelling devices. The facility policy and posted enhanced barrier precaution signage required gowns and gloves for high-contact care activities, including transfers, device care, and wound care. Surveyors observed staff providing hands-on care without the required gown use, despite the residents being identified in care plans and Kardexes as needing enhanced barrier precautions. One resident had diagnoses including severe sepsis with septic shock, necrotizing fasciitis, and obstructive and reflux uropathy, and had an indwelling catheter, two stage 4 pressure ulcers, and two unstageable pressure ulcers. During observation, a CNA transferred the resident from bed to wheelchair using a sit-to-stand lift while wearing gloves and a mask but no gown. The CNA stated they should have worn a gown when providing care and transferring the resident and that they did not notice the enhanced barrier precaution sign because it was posted above the bed rather than outside the room. Another resident had diagnoses including type 2 diabetes, dementia with agitation, and CHF, and had pressure ulcers on both heels. During wound care, an LPN cleansed and dressed both heels, including one wound with malodorous drainage and dark brown/black drainage, while wearing gloves but no gown. The LPN stated they forgot to put on a gown before providing wound care and acknowledged they should have had one on because they were dealing with bodily fluids. The ADON/Infection Preventionist and interim DON stated staff were expected to wear the appropriate PPE, including gowns and gloves, during hands-on care for residents on enhanced barrier precautions.
CNAs Did Not Receive Required Annual In-Service Education
Penalty
Summary
Certified nurse aides were not provided the required annual in-service education for two of five aides reviewed. Certified Nurse Aide #2 completed 5 hours and 12 minutes of in-services and education in 2025, and Certified Nurse Aide #9 completed 3 hours and 24 minutes. The facility policy stated administrators were responsible for ensuring employees attended annual mandatory training, and the educator job description stated the educator was responsible for scheduling and presenting training so nursing assistants completed 6 hours of in-service education every 6 months and for tracking those hours. Interviews showed the educator position changed during the year and there was a period when the facility did not have a staff educator between November 2025 and January 2026. The interim DON stated they had recently gained access to the learning management system and were responsible for monitoring CNA training, while the administrator stated the expectation was that CNAs complete at least 12 hours of in-service education each year. CNA #2 stated they knew they were supposed to complete 12 hours annually, and CNA #9 stated they were not aware of the annual requirement and that education and in-services were not offered consistently.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist responsible for its Infection Prevention and Control Program. The facility policy stated that the Infection Preventionist would oversee implementation of the program and would be designated as an individual with primary professional training in nursing, medical technology, microbiology, epidemiology, or a related field, with specialized education, training, experience, or certification, and working at least part-time at the facility. However, the Assistant DON job description identified the Assistant DON as the Infection Control Preventionist, and a job offer letter showed the Assistant DON was expected to secure Infection Preventionist certification within 30 days of starting the role. During the survey, the Administrator identified the Assistant DON as the Infection Preventionist but initially provided training documentation for the Regional Nurse Consultant and later for the CNO from the Assisted Living Facility, neither of whom were employed part-time or full-time at the nursing home. The Regional Nurse Consultant stated they were focused at another facility and only assisted with questions, and the CNO stated they worked for the Assisted Living Facility and were not acting as the Infection Preventionist for the nursing home. The facility later provided a training certificate for the Assistant DON, and the training transcript showed most modules were completed between 04/15/2026 and 04/20/2026, with 63% completed on 04/20/2026. The Assistant DON stated they had completed the training and took the test on 04/20/2026, while the Administrator stated the Assistant DON had been chosen for infection prevention because it was something they could do and that the training should have been completed within the 30-day timeframe.
Failure to Complete Required Registry Screening Before Hire
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after surveyors found the facility did not follow its written screening process for employees. The facility policy stated that prior to hire, prospective staff would be screened for a history of abuse, mistreatment, neglect, exploitation, or misappropriation of resident property, and that licensing boards and registries would be checked per federal and state requirements. During the survey, the Human Resources Manager stated that Certified Nursing Assistant #12, Activity Leader #1, and Housekeeping Aide #1 were hired before their New York State Nurse Aide Registry verifications were completed. Record review showed Certified Nursing Assistant #12 was hired on 02/25/2026, had a registry verification dated 03/03/2026, and worked on 03/02/2026. Activity Leader #1 was hired on 03/25/2026, had a registry verification dated 04/15/2026, and worked multiple shifts between 03/27/2026 and 04/14/2026 before the verification was completed. Housekeeping Aide #1 was hired on 02/25/2026, had a registry verification dated 03/03/2026, and worked on 02/26/2026, 02/27/2026, and 03/02/2026 before the verification was completed. The deficiency was cited under 10 NYCRR 415.4(b).
Carbon monoxide alarms were not maintained free of dust
Penalty
Summary
The facility failed to comply with Section 915 of the 2025 Fire Code of New York State and related requirements for carbon monoxide detection and maintenance. During the standard survey, surveyors found that the facility had multiple carbon monoxide alarms installed on the first and second floors, including plug-in battery backup models and battery-operated models, while resident sleeping rooms were located on both floors and fuel-burning appliances were located on the first floor. The deficiency affected all four resident units and the service corridor on the two resident-use floors. On observation, surveyors found several carbon monoxide alarms with visible dust accumulation on the top of the covers. On the first floor, a Model A alarm in the corridor between resident rooms was covered with an approximate one-eighth inch layer of dust. On the second floor, two additional Model A alarms in Unit 3 and one Model A alarm in Unit 4 were also observed with the same amount of dust on the covers. On the first floor, two Model B alarms in Unit 2 were observed with an approximate one-eighth inch layer of dust on the covers. In the service corridor kitchen area, three Model C battery-operated carbon monoxide alarms were installed on the walls. The Maintenance Supervisor stated that the facility had two different models of plug-in battery backup carbon monoxide alarms and one battery-operated model, that maintenance staff tested the detectors monthly, and that staff were not cleaning the carbon monoxide alarms. The instruction guides for the alarms stated that the units should be vacuumed regularly or monthly to remove dust, and the facility's CO detector PM checklists showed monthly testing from 01/31/2025 through 03/25/2026.
Failure to Provide and Document COVID-19 Vaccine Education, Consent, and Declination
Penalty
Summary
The deficiency involves the facility’s failure to ensure that when COVID-19 vaccine was available, each resident was properly offered the vaccine, educated on its risks and benefits, and had their decision and education accurately documented in the medical record, as required by facility policy and regulation. The facility’s COVID-19 Vaccine Policy stated that residents who decline vaccination would provide a written affirmation indicating they were offered and declined the vaccine, that vaccination fact sheets would be made available prior to administration, and that informed consent (written or verbal) would be obtained from all individuals being vaccinated. However, the policy did not specify the minimum documentation requirements for the medical record, and in practice, the facility did not consistently obtain or record signed declinations or evidence of education. For one resident reviewed in detail, Resident #3, who had diagnoses including psoriatic arthritis, COPD, and depression and was documented as cognitively intact, the Vaccination Review: Consent/Declination SNF Resident Form showed verbal consent for influenza and a documented decision to decline the COVID-19 vaccine. The declination statement on the form was not signed, and there was no documentation of verbal declination. There was also no evidence in the record that this resident received education regarding the risks and benefits of the COVID-19 vaccine. In interview, Resident #3 stated they wanted to receive the COVID-19 vaccine, reported never receiving written or verbal education about it, and stated they had not signed a declination. An Immunization Audit Report later documented that this resident refused the COVID-19 vaccine on a specific date and that no education was provided. Further review of 34 additional resident Vaccination Review: Consent/Declination forms for residents indicated to have declined the COVID-19 vaccine revealed there were no signed declinations and no documentation that Vaccine Information Sheets or other education on risks, benefits, and potential side effects had been provided to the residents or their representatives. Staff interviews confirmed that when residents declined vaccinations, the declination section of the form should have been completed with a signature or verbal declination notation and that education on risks and benefits should have been provided and documented. The Assistant DON/Infection Preventionist acknowledged responsibility for providing vaccination education but had no evidence that such education was completed, and a former unit manager stated they did not provide vaccination education or obtain consents/declinations for a prior influenza/COVID-19 clinic. Leadership interviews further confirmed expectations that both consent and declination statements be signed when applicable and that risks versus benefits be reviewed prior to obtaining decisions, which did not occur as required in these cases.
Failure to Obtain Proper Consent for COVID-19 and Influenza Vaccinations
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to refuse treatment and to obtain proper consent for immunizations, specifically COVID-19 and influenza vaccines, for two residents reviewed for immunizations. Facility policies for COVID-19 and influenza vaccination required that residents and/or resident representatives receive vaccine information sheets, be educated on risks and benefits, and that informed consent (written or verbal) be obtained prior to administration, with vaccination remaining voluntary. New York State regulations and federal resident rights documents cited in the report state that residents have the right to refuse medication and treatment after being fully informed, and that legal guardians or health care proxies have the right to make important decisions on the resident’s behalf when the resident lacks capacity. Resident #1 had diagnoses including Alzheimer’s disease, vascular dementia, and a prior stroke, with the MDS documenting moderate cognitive impairment. The resident’s care plan showed multiple advance directives, including a MOLST, Health Care Proxy, and Power of Attorney, with a goal that the resident’s wishes be honored. A Determination of Incapacity for Medical Decision-Making documented that the resident lacked capacity and that the Health Care Proxy/Agent had been informed of this determination by two medical providers. Despite this, a Vaccination Review: Consent/Declination form recorded that the Assistant Director of Nursing/Infection Preventionist obtained verbal consent directly from the resident for influenza and COVID-19 vaccines, and the vaccines were administered. The Immunization Audit Report also showed prior refusals of other immunizations by the family/resident, and the order summary confirmed active Health Care Proxy status and vaccine orders. The resident’s Agent/Surrogate later stated they were responsible for medical decisions, were not asked for consent, were only notified after the vaccines were given, and would have declined them. The previous Unit Manager stated that Resident #1 lacked capacity, had documentation of incapacity, and that the spouse should have been called; they further stated that the Assistant DON/Infection Preventionist went room to room obtaining verbal consents from residents without verifying capacity, resulting in vaccinations against the Health Care Proxy’s wishes. Resident #2 had diagnoses including dementia, encephalopathy, and COPD, with the MDS documenting severe cognitive impairment. The care plan described the resident as moderately impaired in decision making and referenced a cognitive level tool indicating Level 4 (moderately impaired). There was no initial documentation of capacity determination or advance directives in the care plan, but later orders showed that a Health Care Proxy was activated with an effective date prior to the vaccination clinic. The Vaccination Review: Consent/Declination form documented that the Assistant DON/Infection Preventionist obtained verbal consent from the resident for influenza and COVID-19 vaccines, and the vaccines were administered. The Immunization Audit Report and order summary confirmed the vaccines were given and that a Health Care Proxy order was in place. The Social Worker stated that a BIMS score under 12 indicated lack of capacity, that Resident #2 did not have the ability to make decisions, and that the Health Care Agent made decisions and should have been notified for vaccinations. The Assistant DON/Infection Preventionist stated they obtained consents verbally from residents and by phone from proxies, that it was not legal to vaccinate without proper consent, and acknowledged they did not document family consent for Resident #2 and should have done so. Resident #2’s Health Care Agent reported that vaccination consent was not discussed with them, they were unaware the vaccines were given, and that the resident would not have understood what they were consenting to. The DON, Administrator, and Medical Director all stated that capacity should be assessed (e.g., via BIMS and capacity forms), that if a resident lacks capacity the responsible party or Health Care Proxy must make decisions, and that residents who lack capacity should not receive vaccinations without proxy consent. These facts collectively demonstrate that the facility failed to ensure residents’ rights to refuse treatment and to obtain appropriate consent from authorized representatives before administering vaccines to two cognitively impaired residents.
Inaccurate Documentation of Third-Party Vaccine Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical record documentation regarding vaccine administration for three residents. Facility policies required that residents receive immunizations from a licensed facility nurse per physician orders, that administration be documented on the Medication Administration Record (MAR), and that vaccines given by non-facility staff be entered as historical documentation in the electronic medical record’s immunization module. Policies also required that medications never be out of the sight of the nurse administering them and that nurses document administration on the MAR immediately after giving the medication, observing the five rights of medication administration. For one resident with Alzheimer’s disease, vascular dementia, and a history of stroke, the MAR for a specified month documented that an LPN administered both a COVID-19 vaccine and an influenza vaccine on a particular date. The Immunization Audit Report showed both vaccines as completed on that date, with incomplete documentation of the COVID-19 vaccine location and administrator, and the influenza vaccine recorded as given in the left deltoid by the Assistant Director of Nursing/Infection Preventionist. For a second resident with dementia, encephalopathy, and COPD, the MAR documented that another LPN administered both COVID-19 and influenza vaccines on the same date, and the Immunization Audit Report showed both as completed, but with incomplete information on the injection site and who administered them. For a third resident with psoriatic arthritis, COPD, and depression, the MAR documented that the same LPN administered an influenza vaccine on that date, and the Immunization Audit Report showed the influenza vaccine as completed in the left deltoid with the administrator field incomplete; this resident was documented as having refused the COVID-19 vaccine. Interviews established that an outside clinic/pharmacist, not facility nurses, actually administered the influenza and COVID-19 vaccines during a Flu/COVID clinic. The Assistant Director of Nursing/Infection Preventionist stated that the pharmacist administered the vaccines and that the correct order type in the electronic medical record should have been “Outside agency Medication/Vaccine Administration,” not a standard MAR medication order. One LPN reported that the outside agency did not have MAR access and that, after verifying which vaccines residents received, they signed the MAR, even though they generally do not sign for medications they did not administer and did not witness one resident’s vaccinations. Another LPN stated they did not administer any vaccines that day and were only entering orders, despite being listed on the MAR as the administering nurse. Other nursing staff and leadership stated that nurses should not document administration of medications they did not give or did not witness, and the Administrator confirmed that nurses should not sign for medications they did not prepare or administer. Despite this, the MAR and immunization records reflected facility nurses as the administering staff or left the administrator field incomplete, while the vaccines were actually given by a third party, resulting in inaccurate medical record documentation.
Deficient Catheter Care and Documentation
Penalty
Summary
A deficiency was identified regarding the care and management of an indwelling Foley catheter for one resident. The resident, who had a history of severe intellectual disabilities, hydronephrosis, urinary retention, and recurrent urinary tract infections, was observed multiple times with the urinary drainage bag positioned above the level of the bladder while seated in a wheelchair. The bag was attached to the wheelchair armrest, contrary to facility policy and standard practice, which require the drainage bag to be kept below bladder level to prevent backflow of urine. Additionally, the resident was not wearing a urinary collection leg bag as specified in the care plan when out of bed. Record review revealed that there were no provider orders in place for the indwelling Foley catheter, including orders for its care or for scheduled catheter changes, despite hospital discharge instructions specifying monthly changes. The resident's comprehensive care plan and Kardex contained inaccuracies, such as references to a suprapubic catheter and nephrostomy tube that the resident did not have. The care plan was not updated to reflect the resident's current urinary status or device needs, and staff interviews confirmed a lack of awareness and follow-through regarding the required catheter care and documentation. Staff interviews further indicated that responsibilities for updating care plans, obtaining provider orders, and ensuring accurate documentation were not consistently fulfilled. Nursing staff and aides were unclear about the correct use of leg bags and the proper placement of drainage bags, and there was a lack of communication regarding changes in the resident's condition and device requirements. The facility's failure to ensure appropriate catheter care, accurate care planning, and proper provider orders led to the identified deficiency.
Verbal Abuse of Resident by Certified Nurse Aide
Penalty
Summary
A deficiency occurred when a certified nurse aide verbally abused a resident during the early morning hours. The aide was witnessed by another resident yelling at the resident, stating that the world did not revolve around them and that they were not special, while also expressing frustration about having other residents to care for. The resident who was the subject of the yelling had diagnoses including congestive heart failure, hypertension, and diabetes mellitus, and was documented as cognitively intact, alert, and oriented. The incident was corroborated by the resident's roommate, who observed the aide's loud and boisterous tone and described the aide as verbally nasty and overcorrecting during care. Multiple interviews with other residents and staff confirmed concerns about the aide's behavior. One resident expressed fear of the aide and described the aide as wanting residents to adapt to their routine. Another resident described the aide's attitude as unpleasant. Staff interviews, including those with an LPN, RN Unit Manager, social worker, and the Director of Nursing, all acknowledged that yelling at residents constituted verbal and mental abuse and was inappropriate. The resident affected by the incident reported feeling disappointed and hurt by the aide's actions. The facility's policies and state regulations require protection of residents from all forms of abuse, including verbal and mental abuse. The investigation confirmed that the aide's conduct was intentional, verbally abusive, and in violation of resident rights. The incident was documented and verified through resident statements, witness accounts, and staff interviews, establishing that the resident was not protected from verbal abuse as required.
Failure to Report Drug Regimen Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist reported irregularities in the drug regimen review for a resident who was prescribed and administered an antibiotic for an excessive duration. The Consultant Pharmacist did not identify or report the prolonged use of Doxycycline Monohydrate, which had been prescribed since November 2020 without an end date. The facility's policy required the pharmacist to assess medication regimens monthly for appropriateness and to report any irregularities, including excessive duration and inadequate indications for use. However, there was no evidence of recommendations made to the provider regarding the continued use of the antibiotic from November 2022 through May 2024. The resident involved had diagnoses including osteomyelitis, pressure ulcers, and schizophrenia, and was documented to have severe cognitive impairment. The comprehensive care plan did not reflect the long-term use of antibiotics, and the Director of Nursing was unaware of the resident's antibiotic use. Interviews with the Pharmacy Consultant and the Chief Nursing Officer revealed a lack of communication and failure to identify and report the irregularities, which was expected as part of the pharmacist's role. The deficiency was identified during a standard survey, highlighting a failure in the facility's medication management and antibiotic stewardship program.
Failure to Monitor Antibiotic Use in Resident with MRSA
Penalty
Summary
The facility failed to ensure that its infection control program included protocols and a system to monitor antibiotic use, as evidenced by the case of a resident who had been receiving Doxycycline Monohydrate for lifelong suppression of Methicillin-Resistant Staphylococcus Aureus (MRSA) since 11/22/20. The resident, who had severe cognitive impairment and multiple diagnoses including osteomyelitis and pressure ulcers, was not monitored or tracked by the Infection Preventionist or the Antibiotic Stewardship Program. The facility's policy required that antibiotic usage be tracked and reported to the Infection Prevention and Control Committee, but this was not done for the resident in question. Interviews with facility staff revealed a lack of awareness and monitoring of the resident's antibiotic use. The Pharmacy Consultant stated that an Antimicrobial Days of Therapy Report was generated monthly and sent to the Administrator, who was expected to share it with relevant staff. However, the Registered Nurse/Infection Preventionist and the Director of Nursing were unaware of the resident's prophylactic antibiotic use, as it did not appear on the facility's monitoring dashboard. The Chief Nursing Officer acknowledged that there was no process in place to review the pharmacy's report, which contributed to the oversight in monitoring the resident's antibiotic use.
Failure to Review and Renew Advanced Directives
Penalty
Summary
The facility failed to ensure that the system for managing advanced directives was implemented in accordance with the residents' wishes, specifically for one resident. The Medical Orders for Life-Sustaining Treatment (MOLST) form for this resident had not been reviewed or renewed since a specified date, despite the facility's policy requiring such reviews at least every 60 days or upon changes in orders. This oversight was identified during a standard survey, which included observations, interviews, and record reviews. The resident in question had a history of cognitive communication deficit, hemiplegia, hemiparesis following a stroke, and type 2 diabetes mellitus. Despite having moderate cognitive impairment, the resident was understood to have expressed a desire for their advance directives to be honored throughout their stay. However, during an interview, the resident expressed a wish to receive CPR, indicating a potential discrepancy between their current wishes and the documented MOLST orders, which included a DNR order and other limitations on medical interventions. Interviews with facility staff, including a Physician Assistant, Social Worker, Registered Nurse Unit Manager, and the Director of Nursing, revealed a lack of consistent review and renewal of the MOLST forms. The staff acknowledged the importance of regularly reviewing these orders to ensure they align with the residents' current wishes and to prevent any medical interventions that might contradict those wishes. The deficiency was further highlighted by the absence of evidence in the social services progress notes that the resident's advanced directives had been reviewed during a specified period.
Medication Labeling and Expiration Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled according to professional principles, specifically in the Unit 4 medication storage room. During an observation, it was found that the refrigerator contained four opened multi-dose vials of Tubersol solution, three of which were undated, and one was outdated. Additionally, the medication storage room cabinet contained expired over-the-counter medications, including liquid Acetaminophen, Sorbitol Solution, and Multi-Vite Liquid. The facility's policy required that only authorized personnel access the medication rooms, and the manufacturer's instructions for Tubersol solution specified that opened vials should be discarded after 30 days. Interviews with staff revealed a lack of adherence to labeling and expiration protocols. A Licensed Practical Nurse admitted to not labeling a new bottle of Tubersol when opened. The Shipping/Receiving Manager stated they were responsible for stocking over-the-counter medications but not refrigerator medications, which were the responsibility of the Pharmacy Technician. The Pharmacy Consultant emphasized the importance of dating multi-dose vials and discarding them after 28 days. The Pharmacy Technician and the Unit Manager both acknowledged the responsibility of nurses to check for expired or unlabeled medications. The Director of Nursing and the Administrator reiterated the expectation that all medication rooms and carts should be free of expired medications and that open vials should be labeled and dated.
Failure to Notify Resident and Family of Room Change and COVID-19 Diagnosis
Penalty
Summary
The facility failed to notify a resident and their responsible party of significant changes, including a room change and a positive COVID-19 test result. Specifically, the resident's room was changed on 11/30/23 without notifying the resident or their family member, as required by the facility's policy. Interviews with the social worker and the Director of Social Work confirmed that there was no documentation of notification, and the family member stated they were not informed of the room change. Additionally, the resident tested positive for COVID-19 on 12/17/23, but there was no evidence that the responsible party was notified. The family member discovered the resident's condition upon visiting the facility and expressed dissatisfaction with the lack of communication. Interviews with nursing staff and the Director of Nursing revealed that the unit manager should have notified the family immediately about the change in condition, but there was no documentation of such notification in the resident's records.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure the personal privacy of a resident during personal care, as observed during a complaint investigation. The incident involved a resident with diagnoses including congestive heart failure, ischemic cardiomyopathy, and osteoarthritis, who was dependent on staff for toileting hygiene. During an observation, a Certified Nursing Assistant (CNA) initiated incontinent care for the resident but left the resident exposed and uncovered, visible to the hallway, when exiting the room. The resident expressed discomfort about being left exposed, and the CNA returned with another CNA to complete the care but again left the resident uncovered with the door open. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that all nursing staff were responsible for ensuring personal privacy during care to maintain residents' dignity. The CNAs involved acknowledged the failure to cover the resident and close the door, which compromised the resident's dignity and privacy. The facility's policies emphasized the importance of respecting residents' rights to privacy and dignity, which were not adhered to in this instance.
Delay in Radiology Services for Resident After Fall
Penalty
Summary
The facility failed to provide timely radiology services for a resident who required a lumbar x-ray following an unwitnessed fall. The resident, who had a history of dementia, hemiparesis, and repeated falls, was found on the floor complaining of lower back and elbow pain. Although x-rays for the elbow and sacral regions were ordered and completed, the lumbar x-ray was not performed until several days later, resulting in a delay in treatment. The deficiency was primarily due to a breakdown in communication and documentation processes. Registered Nurse #1 did not enter the x-ray orders into the electronic medical record, and the Unit Clerk was not informed of the new orders through the usual method of writing them in a designated book. This miscommunication led to the omission of the lumbar x-ray from the initial radiology request, despite the Nurse Practitioner having ordered it. Interviews with staff, including the Unit Clerk, Registered Nurse #1, the Nurse Practitioner, and the Director of Nursing, revealed inconsistencies in the process of ordering and documenting x-rays. The Director of Nursing acknowledged the communication breakdown, and the Medical Doctor confirmed that all x-rays should have been completed as ordered. The failure to obtain the lumbar x-ray promptly was identified as a deficiency in meeting the resident's needs.
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What surveyors actually found near you
We read the 163 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Cheektowaga
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Gate Health Care Facility | 1.1 mi | ★★★★★ | 0 | 0 |
| Elderwood At Lancaster | 3.1 mi | ★★★★★ | 2 | 0 |
| Seneca Health Care Center | 3.9 mi | ★★★★★ | 1 | 0 |
| Williamsville Suburban, L L C | 4.6 mi | ★★★★★ | 9 | 0 |
| Terrace View Long Term Care Facility | 4.9 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.