Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elderwood At Hamburg during CMS and state inspections, most recent first.
Two residents who required max assist of two staff for bed mobility were rolled in bed with the bed brakes unlocked and without proper two-person positioning, causing the beds to move away from the wall and the residents to fall between the bed and the wall. One resident with a recent BKA and muscle weakness fell during personal care when only one CNA actively rolled the resident toward the wall on an unlocked bed, later being found to have a nondisplaced radial head fracture. Another resident with COPD, DM2, and lower extremity impairments fell while being dressed in bed when a CNA rolled the resident toward the wall on an unsecured bed, resulting in head and facial lacerations and a comminuted nondisplaced fracture of the third metacarpal. In both cases, the documented care plans and Kardex required two-person assistance for rolling in bed, and staff and leadership interviews confirmed that the falls occurred during care with unlocked beds and without adherence to the two-person bed mobility requirement.
A resident with anxiety, major depression, schizophrenia, anticoagulant therapy, tardive dyskinesia, and fibromyalgia did not receive all ordered bedtime medications when an LPN found that some medications were not in the med cart and did not use available pill packs in the med room. The LPN administered only narcotics and stock medications, failed to notify the nursing supervisor, pharmacy, or physician that medications were unavailable, and documented in the eMAR that all bedtime medications were given. There was no progress note indicating omitted doses or provider notification, and the resident later reported not receiving their medications and complained of worsened tardive dyskinesia symptoms, while the physician and nursing staff reported they had not been informed of the omissions.
A resident with severe cognitive impairment was allegedly slapped on the head by a CNA, but the incident was not reported immediately by the witnessing CNA due to fear of retaliation. The delay resulted in the Administrator and state authorities being notified well beyond the required two-hour timeframe, contrary to facility policy and state regulations.
Failure to Lock Beds and Provide Required Two-Person Assistance During Bed Mobility Resulting in Falls and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and use of assistive devices during resident repositioning and bed mobility, resulting in falls and fractures for two residents. Facility policy defined accidents and falls and required thorough assessment, appropriate interventions such as adequate supervision and assistive devices, and adherence to safety practices including locking bed systems. The bed manufacturer’s user manual also warned that the Care-Lock feature should be locked at all times except when moving the bed and that an unlocked bed should never be left unattended. Despite these requirements, staff provided care with beds unlocked and without the required number of assisting staff, leading to residents falling between the bed and the wall. For the first resident, who had a right below-knee amputation, diabetes mellitus, and muscle weakness, the MDS and care plan documented that the resident was cognitively intact and required substantial/maximal assistance of two staff for rolling left and right in bed. The Kardex also specified two-person assistance for bed mobility. On the evening of the incident, the resident was being provided personal care when a CNA instructed the resident to roll toward the wall. Statements and interviews indicated that only one CNA was actively rolling the resident, the second CNA was at the foot of the bed rather than positioned on the opposite side, and the bed was not locked. As the resident rolled toward the wall, the unlocked bed moved away, and the resident slid or fell between the bed and the wall, striking the wall and floor. The resident reported that the CNA forcefully rolled them using the draw sheet, that their right hand hit the wall, and that the bed rolled away, causing them to fall and hit their head. Following this fall, the resident complained of pain in the right shoulder, knee, and elbow. Initial x-rays of the right elbow were documented as normal, but the resident continued to report right arm and elbow pain. Subsequent imaging later identified a fracture involving the radial head/neck of the right elbow, and an orthopedic consult diagnosed a nondisplaced radial head fracture. Therapy documentation noted that the resident’s rehabilitation was complicated by the elbow fracture, which required non-weight-bearing status of the right upper extremity and affected functional mobility. Multiple staff interviews, including with the PA, DON, nurse educator, LPNs, physical therapist, and medical director, consistently described that the bed was not locked, that the resident required two-person assistance for bed mobility, and that only one CNA was in proper position to roll the resident at the time of the fall. For the second resident, who had COPD, type 2 diabetes mellitus, depression, and lower extremity impairments, the MDS and care plan documented that the resident was cognitively intact, required maximum assist of two staff for bed mobility to turn right and left, and was at risk for falls. The Kardex documented dependence on two or more staff to roll left and right in bed. During early morning care, a CNA was dressing the resident and rolled the resident toward the wall to pull down the shirt and place a sling under them. The CNA reported that the resident put a hand on the wall for support and that the bed began to move away from the wall. The CNA attempted to hold the resident but was unable to prevent the resident from falling between the bed and the wall. The incident report documented that this was a witnessed fall out of bed during care, resulting in lacerations to the back of the head, right elbow, and right eyebrow. After this fall, the resident was sent to the hospital, where records documented a head injury and laceration repair to the forehead. Upon return, the resident complained of facial pain and left hand pain; assessment revealed swelling, bruising, and pain with range of motion of the left middle finger. An x-ray showed a comminuted nondisplaced fracture of the third metacarpal of the left hand. Interviews with supervisory nursing and rehabilitation staff indicated that the resident required one assist for dressing but two staff for bed mobility at the time, and that the resident fell when rolled toward the wall during care. Staff and leadership acknowledged uncertainty about whether the bed was locked but described the resident as found between the bed and the wall and characterized the event as a failure to follow the care plan and to ensure the bed was secured during care.
Failure to Administer and Accurately Document Bedtime Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services and medication administration met professional standards of quality for one resident. The resident had diagnoses including anxiety disorder, major depressive disorder, schizophrenia, a history of pulmonary embolism, and transient ischemic attack, and was on anticoagulant therapy with a care plan that required medications to be administered as ordered and monitoring for side effects. The resident also received psychotropic medications for depression, anxiety, tardive dyskinesia, and fibromyalgia, with care plan interventions to administer medications as ordered, monitor effectiveness, and update the medical provider as needed. On an evening in November, the resident did not receive all of their ordered bedtime medications. The electronic Medication Administration Record showed multiple medications scheduled at bedtime, including Buspirone, Caplyta, Eliquis, Floranex, Lipitor, Lyrica, Oxycodone, Polyethylene glycol, Senna S, Simethicone, Topiramate, Valbenazine, and Zyrtec. LPN #3 signed all of these medications as administered, but later stated that only the narcotics and stock medications were actually given because the other evening medications were not in the medication cart. Statements from staff and the facility’s investigation indicated that a new 7‑day supply of pill packs for the resident was in the medication room and had not been placed into the medication cart, and that LPN #3 either did not recognize or did not use these pill packs to administer the remaining medications. The facility’s records and interviews showed that LPN #3 did not notify the nursing supervisor, pharmacy, or the medical provider that the resident’s evening medications were unavailable and omitted, and there was no documentation in the progress notes that the medications were unavailable or that a provider was consulted for new orders. The resident later reported to staff that they had not received their evening medications and complained of increased tardive dyskinesia symptoms, although nursing and the physician reported they did not observe increased symptoms at that time. The physician and pharmacy consultant both stated they were not aware of being notified about the omitted medications and emphasized that medications should not be documented as given if they were not administered. The facility’s policies required immediate and accurate documentation of medication administration, notation and reporting of withheld medications, and prompt notification of the physician when treatment needed to be significantly altered, but these requirements were not followed in this incident.
Delayed Reporting of Suspected Abuse
Penalty
Summary
Staff failed to immediately report an allegation of physical abuse involving a resident with severe cognitive impairment, dementia, depression, and hypertension. The incident occurred when a Certified Nurse Aide (CNA) witnessed another CNA slap the resident on the head while the resident was sleeping in a wheelchair. The witnessing CNA did not report the incident immediately due to fear of retaliation, instead waiting approximately eleven days before informing an LPN. The LPN then reported the allegation to the Director of Nursing, and the incident was subsequently reported to the Administrator and the State Department of Health. Facility policy required all staff to immediately report any observed or suspected abuse to the Administrator, Director of Nursing, or designee, and for the Administrator or designee to notify state agencies within two hours. However, the delay in reporting by the CNA resulted in the Administrator and state authorities being notified well outside the required timeframe. Interviews with staff confirmed knowledge of the reporting requirements and acknowledged that the delay was unacceptable.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 144 citations issued within 25 miles in the last 12 months — including the 3 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hamburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn View Health Care Facility L L C | 0.4 mi | ★★★★★ | 3 | 0 |
| Father Baker Manor | 4 mi | ★★★★★ | 1 | 1 |
| Fox Run At Orchard Park | 4.8 mi | ★★★★★ | 0 | 0 |
| Mercy Hospital Skilled Nursing Facility | 6.1 mi | ★★★★★ | 0 | 0 |
| Eden Rehabilitation Nursing Center | 6.4 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Elderwood At Hamburg.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.