Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Lancaster during CMS and state inspections, most recent first.
A maintenance staff member entered a resident's room without a valid work order and engaged in verbally abusive behavior, repeatedly and loudly accusing the resident of attempting to spit on a nurse manager. The resident, who was cognitively intact and had multiple medical conditions, denied the accusation and called 911 after feeling unsafe. Audio and video evidence, as well as staff interviews, confirmed the staff member's conduct was aggressive, disrespectful, and in violation of resident rights.
A resident with intact cognition alleged verbal and physical abuse by a staff member, including threatening statements and contact with an injured ankle. Although the incident was reported internally, the facility failed to notify the State Agency within the required two-hour timeframe, resulting in a deficiency for not adhering to mandated abuse reporting protocols.
The facility failed to maintain sufficient nursing staff, particularly CNAs, to meet residents' needs, resulting in long wait times for call light responses and delayed incontinent care. Residents reported waiting over half an hour for assistance, especially during night shifts and weekends. Staff interviews confirmed frequent understaffing, with CNAs and nurses unable to complete all duties. Despite management's awareness, the facility did not effectively address the staffing shortages, compromising resident care.
The facility failed to comply with regulations by allowing the DON to serve as a charge nurse when the average daily census exceeded 60 residents. Due to staffing shortages, the DON frequently worked as a charge nurse or LPN, despite the facility's census consistently being over 60. Interviews and staffing sheets confirmed the DON's involvement in direct resident care and supervisory roles, contrary to regulatory requirements.
The facility failed to provide or arrange for dental services for its residents, affecting all 83 residents. A resident had not seen a dentist since admission, and staff interviews revealed that in-house dental services had not been provided since April 2024. The facility lacked a cooperative agreement with an outside dental service, leaving residents to arrange their own care.
Two residents were denied their right to vote in the 2024 Presidential Election due to the facility's failure to implement its voting policy. Despite being cognitively intact and expressing a desire to vote, they did not receive absentee ballots or information about voting opportunities. Interviews revealed a lack of communication and documentation, with the Director of Activities unaware of residents' voting preferences and no system in place to track interest in voting.
A resident was found self-administering medications without an assessment by the interdisciplinary team or a physician's order, contrary to facility policy. The resident, with a history of cerebral infarction and COPD, had medications in their room without proper documentation or monitoring by nursing staff. Interviews revealed a lack of formal evaluation and concerns about medication misuse.
A resident's responsible party was not notified of a new psychotropic medication, Rexulti, and its dosage increase, despite the facility's policy requiring immediate notification. The resident, with severe cognitive impairment, was prescribed Rexulti without informing the responsible party, who only learned of it after receiving a bill. Interviews with staff revealed confusion over notification responsibilities, leading to a communication breakdown.
The facility failed to maintain a safe and clean environment, with ongoing roof leaks in Unit 2, foul odors in a shower room, and improper maintenance of oxygen concentrator filters. The roof leaks resulted in wet ceiling tiles and water on the carpet, while the shower room had strong odors and a broken shower chair with sharp edges. Additionally, oxygen concentrator filters were not cleaned as recommended, posing an infection risk.
Two residents in an LTC facility did not receive necessary care for activities of daily living. One resident was left in a saturated state with urine due to a lack of assigned staff, while another had long, dirty fingernails due to insufficient nail care. Staff interviews revealed that these deficiencies were largely due to staffing shortages, which hindered the ability to provide timely and adequate care.
A resident with dementia was left with medications unattended at their bedside, despite lacking a physician's order for self-administration. An LPN signed the medications as administered without ensuring they were taken, contrary to facility policy. This posed a safety risk, as confirmed by the RN Unit Manager, DON, and Administrator.
The facility failed to maintain proper infection control practices, as staff did not wear appropriate PPE or follow protocols for residents requiring enhanced barrier precautions. A resident with a urinary catheter had tubing on the floor, and staff did not change gloves after catheter care. Another resident with chronic wounds lacked signage and PPE, indicating systemic issues in infection control.
A resident with severe cognitive impairment and a pressure ulcer was not provided with posey boots as required by their care plan. Despite policies emphasizing the use of specialized devices for pressure ulcer management, the resident was observed without the necessary footwear on multiple occasions. Staff interviews revealed a lack of awareness and communication regarding the resident's needs, contributing to the deficiency.
Verbal Abuse by Maintenance Staff Toward Resident
Penalty
Summary
A deficiency occurred when a maintenance staff member engaged in verbally abusive behavior toward a resident. The incident began after the resident had expressed care concerns from the previous evening and had an interaction with a unit manager, during which the resident was told they could leave against medical advice if they wished to be discharged. Shortly after, the maintenance staff member entered the resident's room without a work order or valid reason, rapidly knocked, and confronted the resident in a loud and disrespectful manner, repeatedly accusing the resident of attempting to spit on the unit manager. This confrontation was captured on an audio recording made by the resident and corroborated by facility video footage. The resident, who had diagnoses including a left leg fracture, muscle weakness, and obesity, was cognitively intact and able to communicate effectively. During the incident, the resident remained calm and denied the accusations, while the maintenance staff member insisted on the claim and stated that the resident needed to be removed from the facility. The resident subsequently called 911, reporting that they felt unsafe due to the staff's behavior. Multiple staff interviews confirmed that the maintenance staff member's tone was loud, aggressive, and accusatory, and that their actions were considered verbally abusive and unprofessional. Facility policy and New York State regulations require that residents be protected from all forms of abuse, including verbal abuse. The investigation revealed that the maintenance staff member acted outside their scope of duties, entered the resident's room without proper cause, and failed to treat the resident with dignity and respect. The staff member's behavior was acknowledged by facility leadership and other staff as inappropriate, undignified, and in violation of resident rights.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of staff-to-resident verbal and physical abuse within the required two-hour timeframe to the State Survey Agency and other appropriate authorities. According to the facility's policy, all alleged violations involving abuse must be reported immediately, but no later than two hours after the allegation is made. In this case, an incident involving a resident and a staff member was reported to the facility Administrator via email, but the report to the State Agency was not made until several days later, well beyond the required timeframe. The Administrator acknowledged awareness of the allegation but did not submit the report as required, citing forgetfulness. The incident involved a resident with intact cognition who alleged that a staff member entered their room, made threatening statements, and made physical contact with the resident's injured ankle. The resident called emergency services, and law enforcement responded to the facility. The facility's investigation concluded that verbal abuse had occurred. Despite these findings and the facility's established policy, the delay in reporting the allegation constituted a failure to comply with regulatory requirements for timely reporting of abuse.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff on a 24-hour basis to meet the needs of all residents, as evidenced by a complaint investigation and standard survey. The facility's assessed minimum staffing levels for Certified Nurse Aides (CNAs) were not met, particularly during the night shifts. The facility's emergency staffing plan, which included utilizing an internal float pool and third-party agency staff, was not effectively implemented, leading to staffing shortages. Interviews with residents revealed that they experienced long wait times for call lights to be answered, particularly during the night and on weekends, indicating a lack of adequate care. Multiple residents reported waiting over half an hour for assistance, with some experiencing delays in receiving incontinent care, resulting in discomfort and unsanitary conditions. Staff interviews corroborated these findings, with CNAs and nurses frequently working understaffed shifts, unable to complete all required duties such as emptying catheter bags and providing timely incontinent care. The facility's staffing sheets documented several instances where the number of CNAs on duty fell below the minimum required levels, further supporting the residents' complaints. The facility's administration and management were aware of the staffing issues, as indicated by interviews with the Administrator and Director of Nursing. Despite this awareness, the facility failed to address the staffing shortages effectively, leading to compromised care for residents. Staff members expressed concerns about being overworked and unable to provide the quality of care expected, with some staff leaving due to the ongoing staffing challenges. The facility's failure to maintain adequate staffing levels resulted in a deficiency in providing necessary care to residents, as required by state regulations.
Director of Nursing Improperly Assigned as Charge Nurse
Penalty
Summary
The facility failed to comply with regulations by allowing the Director of Nursing (DON) to serve as a charge nurse when the facility's average daily census exceeded 60 residents. The facility's documentation and interviews revealed that the DON was frequently assigned to work as a charge nurse or Licensed Practical Nurse (LPN) due to staffing shortages. This was observed on multiple occasions, as documented in the facility's daily staffing sheets and confirmed through interviews with the DON and other staff members. The facility's census reports indicated that the number of residents consistently exceeded 60, with counts ranging from 83 to 87 during the survey period. Despite this, the DON was repeatedly assigned to roles typically filled by other nursing staff, such as supervising the building, passing medications, and admitting new residents. The DON reported working significant overtime to cover these duties, which included working on nurse carts and providing direct resident care. Interviews with the Clinical Scheduling Specialist and the Administrator confirmed that the DON was called upon to fill in for staffing shortages, particularly on weekends. The Administrator and DON both stated they were unaware of the regulation prohibiting the DON from serving as a charge nurse when the facility's occupancy was over 60 residents. This oversight led to the DON working in roles outside of their designated responsibilities, contributing to the deficiency noted in the survey.
Deficiency in Dental Services Provision
Penalty
Summary
The facility failed to employ a qualified professional to provide dental services or arrange for such services through an external provider, affecting all 83 residents. Specifically, the facility did not have a dentist on staff and did not have an arrangement with an outside dental service provider. This deficiency was highlighted by the case of a resident who had not seen a dentist since admission, despite having signed a consent form for dental examinations and treatments. Interviews with various staff members, including LPNs, RNs, and the Medical Records Specialist, revealed that the facility had not provided in-house dental services since April 2024. Staff members were unsure of when a dentist last visited the facility, and some residents were left to arrange their own dental care. The facility's documentation indicated that routine dental services were not being provided, and there was no cooperative agreement with an outside dental service. The Administrator and other staff members acknowledged the lack of dental services and stated that they were assisting residents' families in setting up appointments with community dentists. However, the facility did not provide transportation for these appointments, and residents without family support were left without adequate dental care. The Chief Business Development Officer confirmed that the facility had been using a county dental clinic for Medicaid residents but had no current contract with a dentist for in-house services.
Failure to Facilitate Resident Voting Rights
Penalty
Summary
The facility failed to ensure that residents were afforded their right to vote in the November 2024 Presidential Election, as evidenced by the experiences of two residents. The facility's policy, dated July 2018, required the Director of Activities, in cooperation with the Director of Social Services and the Board of Elections, to facilitate voting for residents. However, this policy was not effectively implemented, resulting in residents not receiving absentee ballots or being informed about voting opportunities. Resident #19, who was cognitively intact and had expressed a strong desire to vote, did not receive an absentee ballot and was unable to participate in the election. The resident's family member confirmed the importance of voting to the resident and expected the facility to provide the necessary absentee ballot. Similarly, Resident #49, also cognitively intact and the Resident Council President, was not informed about the voting process and did not receive an absentee ballot, despite having participated in voting previously. Interviews with facility staff revealed a lack of communication and documentation regarding the voting process. The Director of Activities #1, who took over shortly before the election, was unaware of the residents' voting preferences and did not have a system in place to track residents' interest in voting. The Board of Elections confirmed that the facility had not updated residents' addresses or facilitated the absentee ballot process. The Administrator acknowledged the need for a tracking system and annual interviews to ensure residents' voting rights were respected.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed by the interdisciplinary team to determine their ability to safely self-administer medications. Specifically, a resident was observed with medications in their room and stated they self-administered these medications without an evaluation to confirm their capability to do so safely. The facility's policy requires that residents who wish to self-administer medications must be reviewed and approved by the interdisciplinary care planning team, with an order from the attending physician, and that the use of self-administered medication should be monitored by licensed nursing staff. The resident in question had a history of cerebral infarction, atherosclerosis, embolism, thrombosis, and chronic obstructive pulmonary disease (COPD). Despite being documented as independent in decision-making and having no cognitive impairment, there was no evidence of an active physician's order for the resident to self-administer medications or for the medications to be left at the bedside. Additionally, there was no documented assessment by the interdisciplinary team or monitoring by licensed nurses as required by the facility's policy. Interviews with facility staff revealed that the resident's inhalers were found on a tray table in their room, and the resident stated they used them as needed. A registered nurse confirmed that there was no order for one of the inhalers and expressed concerns about the lack of monitoring and potential misuse by other residents. The Director of Nursing stated that a self-administration assessment should be completed, and an order should be in place for all self-administered medications, with documentation of the resident's ability to safely self-administer the medication.
Failure to Notify Responsible Party of Medication Change
Penalty
Summary
The facility failed to ensure that the responsible party of a resident was notified immediately when there was a significant change in the resident's mental and psychological condition, requiring a change in treatment. Specifically, the facility did not inform the responsible party of the initiation and subsequent increase in dosage of a new psychotropic medication, Rexulti, for a resident diagnosed with dementia and other behavioral disturbances. The facility's policy required immediate notification of the resident's legal representative when there was a need to alter treatment significantly, but this was not adhered to in this case. The resident in question was severely cognitively impaired and had been receiving antipsychotic medications routinely. A new order for Rexulti was initiated, and the dosage was increased without documented evidence of notification to the responsible party. The responsible party only became aware of the new medication after receiving a bill, which led to concerns about the medication's necessity and cost. Despite the facility's policy and the expectation that the responsible party should be involved in medical decisions, there was a lack of communication regarding the medication changes. Interviews with facility staff, including a Licensed Practical Nurse, Social Worker, Director of Nursing, and Physician Assistant, revealed a lack of clarity and responsibility regarding who should notify the responsible party of medication changes. The staff assumed that the responsible party was being informed by others, leading to a breakdown in communication. The Director of Nursing acknowledged the expectation for immediate notification but admitted that the responsible party was not informed of the new order for Rexulti.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by several deficiencies observed during the survey. The roof above Unit 2 had ongoing leaks, which resulted in wet ceiling tiles and water dripping onto the carpeted floors. Despite attempts to address the issue, such as replacing the curb around the rooftop unit and changing absorbent ceiling tiles, the problem persisted. Interviews with staff revealed that the roof had been patched multiple times, and discussions about replacing it were ongoing. The leaks were a known issue, with staff placing buckets to catch water during heavy rains. In the Unit 2 shower room, strong odors of urine and feces were present, and the room was not maintained properly. Garbage totes were left uncovered, and soiled linens and briefs were not removed promptly, contributing to the foul odor. A shower chair in disrepair, with sharp jagged edges on the footrest, posed a risk of injury to residents. Staff interviews indicated a lack of awareness and action regarding the maintenance of the shower room and equipment, with expectations for cleanliness and safety not being met. The facility also failed to adhere to the manufacturer's recommendations for maintaining oxygen concentrator filters. Observations revealed that the filters on the oxygen concentrators were dust-laden and not cleaned weekly as required. Maintenance staff replaced the filters monthly but did not wash them, and nursing staff were unaware of their responsibility to clean the filters. This oversight could lead to the accumulation of dust and bacteria, potentially causing infections. The lack of proper maintenance and cleaning of the oxygen concentrators was a significant deficiency in the facility's infection control practices.
Deficiencies in Resident Care Due to Staffing Issues
Penalty
Summary
The facility failed to provide necessary services for activities of daily living to two residents, resulting in deficiencies in personal hygiene and grooming. Resident #16, who had diagnoses including dementia, hypertension, and congestive heart failure, was not provided timely incontinence care. Observations revealed that Resident #16 was left in a saturated state with urine from 6:00 AM until 10:37 AM, when care was finally provided. Interviews with staff confirmed that there was no Certified Nurse Aide assigned to Resident #16 during this period, leading to a lack of care and attention to the resident's needs. Resident #79, diagnosed with metabolic encephalopathy, pneumonia, and dysphagia, was found with long, dirty fingernails containing dark brown debris. Despite the resident's preference for a bed bath and the requirement for substantial assistance with personal hygiene, nail care was neglected. Observations and interviews indicated that staff were aware of the need for nail care but were unable to provide it due to being short-staffed. The lack of nail care was attributed to the heavy workload and insufficient staffing, which prevented staff from attending to such details. The facility's policies on hygiene and grooming, perineal care, and nail care were not adhered to, resulting in these deficiencies. Staff interviews revealed that the lack of staffing contributed significantly to the failure to provide adequate care. The Director of Nursing acknowledged the issue, noting that the shortage of staff made it difficult to address all aspects of resident care, including nail care and incontinence management.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were securely stored and administered according to State and Federal laws. Specifically, medications were left unattended at the bedside of a resident with dementia, who lacked decision-making capacity and experienced periods of confusion. The resident had no physician's order to self-administer medications, yet medications including Folic Acid, Sertraline, Vitamin B-1, and Lactulose Solution were left on the over-the-bed table. The Licensed Practical Nurse (LPN) responsible for administering these medications signed them as administered without ensuring the resident took them, which was against the facility's policy. The incident was observed by a Certified Nurse Aide who noted the medications should not have been left unattended, as it posed a safety risk. The LPN admitted to leaving the medications, assuming the resident would take them, and acknowledged the importance of staying with the resident to ensure the medications were swallowed. The Registered Nurse Unit Manager and the Director of Nursing both confirmed that the LPN should have watched the resident take the medications and that leaving them unattended was a safety risk. The facility's Administrator also acknowledged the safety risk posed by leaving medications at the bedside.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a standard survey. Specifically, staff did not adhere to proper infection control measures when providing care to residents with indwelling catheters and those requiring enhanced barrier precautions. For Resident #2, staff were observed not wearing appropriate personal protective equipment (PPE) such as gowns during high-contact care activities, despite the resident being on enhanced barrier precautions due to a urinary catheter. Additionally, the resident's catheter tubing was repeatedly observed on the floor, which is against infection control protocols. Further observations revealed that staff failed to change gloves after performing urinary catheter care and before touching other surfaces or providing additional care, increasing the risk of cross-contamination. Certified Nurse Aides involved in the care of Resident #2 admitted to not following PPE protocols and acknowledged the potential for spreading infection. The facility's infection control policies did not adequately address the use of a blue diamond identification system for residents on enhanced barrier precautions, leading to inconsistencies in staff awareness and practice. Resident #11, who required enhanced barrier precautions due to chronic wounds, was also affected by the facility's inadequate infection control measures. There was no signage or PPE available outside or inside the resident's room, and staff were not observed wearing the necessary protective gear. Interviews with facility staff, including the Director of Nursing and the Clinical Educator/Infection Preventionist, confirmed that enhanced barrier precautions were not properly implemented for Resident #11, highlighting a systemic issue in the facility's infection control practices.
Failure to Implement Care Plan for Pressure Ulcer Management
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with a pressure ulcer, as observed during an abbreviated survey. The resident, who had diagnoses including unspecified dementia, epilepsy, and generalized osteoarthritis, was severely cognitively impaired and dependent on activities of daily living. The care plan required the resident to wear posey boots at all times to prevent further skin breakdown, but the resident was observed without them on multiple occasions. The facility's policy on pressure ulcers and skin conditions emphasized the need for specialized devices to prevent and treat such conditions. Despite this, the resident was seen without the necessary therapeutic footwear during several observations, both in bed and in a wheelchair. The Treatment Administration Record indicated that the posey boots were not applied during certain shifts, and staff interviews revealed a lack of awareness and communication regarding the resident's needs. Interviews with various staff members, including CNAs, LPNs, and the interim Director of Nursing, highlighted inconsistencies in the application of the care plan. Some staff were unaware of the resident's need for posey boots, while others reported the absence of the boots but did not ensure their availability. The Wound Consultant confirmed that offloading pressure was crucial for the resident's condition, and the lack of compliance with the care plan could have contributed to the stagnation of the healing process.
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 162 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 Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenfield Health & Rehab Center | 2.7 mi | ★★★★★ | 1 | 0 |
| Elderwood At Cheektowaga | 3.1 mi | ★★★★★ | 4 | 0 |
| Garden Gate Health Care Facility | 3.7 mi | ★★★★★ | 0 | 0 |
| Harris Hill Nursing Facility, L L C | 4.4 mi | ★★★★★ | 9 | 0 |
| Williamsville Suburban, L L C | 5.6 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Elderwood At Lancaster.
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.