NIAGARA FALLS, NY — A federal health inspection completed on August 14, 2024, found widespread staffing deficiencies at Elderwood at Wheatfield, a 123-bed nursing home on Niagara Falls Boulevard. Inspectors documented residents left in soiled bedding for hours, showers missed for weeks at a time, and call lights turned off without staff returning to help — all tied to a chronic failure to maintain even the facility's own minimum staffing requirements.
The inspection, conducted by the Centers for Medicare and Medicaid Services, cited the facility for multiple deficiencies including inadequate nurse staffing, infection control failures, pest infestations, and lapses in providing prescribed adaptive eating equipment.
Resident Found in Bed Saturated With Urine and Feces
The inspection report's most striking finding involved a direct observation by surveyors on August 8, 2024. At 11:10 AM, inspectors watched as a certified nurse aide transferred Resident #82 out of bed using a stand lift. The resident's incontinence brief was saturated with urine and feces that oozed from its edges, and both the bed sheet and draw sheet were soaked.
The aide told inspectors that the 6:00 AM shift had begun more than five hours earlier, and this was the first opportunity they had to provide care to that resident because the unit was short-staffed. Resident #82 confirmed they had been waiting "for a while."
This was not an isolated incident. Under federal regulations, nursing homes must ensure incontinent residents receive care every two to four hours. At Elderwood at Wheatfield, staff told inspectors this standard was routinely unmet due to the number of aides on duty.
Prolonged exposure to urine and feces poses serious medical risks for elderly residents. Contact with these waste products breaks down skin integrity, particularly in individuals with limited mobility. This can lead to moisture-associated skin damage, pressure injuries, and urinary tract infections. For residents already managing chronic conditions, these complications can escalate rapidly and become life-threatening.
A Pattern of Missed Care Across Multiple Units
The staffing problems extended well beyond a single incident. Inspectors reviewed daily staffing sheets from July 8 through August 14, 2024, and identified nine separate dates when the facility fell below its own minimum staffing plan. The shortages ranged from half a CNA position to a full aide missing from a shift.
The facility's master staffing plan called for just one nurse and two certified nurse aides per unit on day and evening shifts — a ratio that staff themselves described as insufficient. With a census of approximately 107 residents across three units, individual aides were responsible for 19 to 24 residents during a typical shift.
The consequences were documented across interviews with more than a dozen residents, family members, and staff:
- Showers missed for weeks: One resident's family member reported the resident had not received a shower in three weeks. Another resident said they were "lucky if they got a shower once a week." Multiple residents reported going an entire week or longer without bathing.
- Late morning care: Residents from Unit 2 formally raised concerns at a June 2024 Resident Council meeting that they were not being gotten out of bed until after lunch. One resident stated they wanted to be up by 10:00 AM but were "mostly never" out of bed by then.
- Extended waits for toileting: A family member of one resident who required two-person assistance reported that finding a second aide "could take hours." Staff confirmed that residents sometimes became incontinent because toileting could not be provided in time.
- Delayed pain medication: One resident reported waiting up to an hour for pain medication on some nights.
- Call lights ignored: During Resident Council interviews, multiple residents stated that staff would enter rooms, turn off call lights, promise to return, and then fail to come back, forcing residents to reactivate their call lights.
Staff Described Conditions as Unsustainable
What distinguishes this inspection is the consistency of staff testimony. Aides, nurses, and managers across all levels described the same problem independently.
A certified nurse aide with 33 years at the facility stated that staffing was "currently at its worst." Licensed Practical Nurse #9 told inspectors they knew at the start of their shift they would not be able to complete all required work, adding: "The residents were being unintentionally neglected because of the lack of staff."
The Acting Unit Manager and Assistant Director of Nursing — a management-level employee — told inspectors that two nurses and two CNAs on Unit 2 "was not enough staff to provide adequate care to all residents due to the high acuity of the unit." They stated the Director of Nursing and Administrator were aware of the shortfall.
Even the facility's activities program was affected. An activities aide who also held CNA certification reported frequently being pulled from recreational programming to assist with basic resident care.
Night shift conditions were particularly concerning. One CNA who worked the 10:00 PM to 6:00 AM shift reported being the only aide on the unit, stating they could typically complete only one round of incontinent care during the entire eight-hour shift because they also needed to attend to residents with behavioral needs.
Why Minimum Staffing Ratios Matter
Federal regulations under 42 CFR 483.35 require nursing homes to maintain "sufficient nursing staff" to provide care in accordance with each resident's care plan. When facilities operate below their own stated minimums, the consequences cascade through every aspect of daily care.
Inadequate staffing directly correlates with increased rates of pressure ulcers, urinary tract infections, weight loss, and falls. For residents who are incontinent, regular repositioning and hygiene care is not optional — it is a clinical necessity. Extended contact with moisture causes maceration of the skin, creating entry points for bacteria and dramatically increasing infection risk.
Similarly, missed showers are not merely a comfort issue. Regular bathing is an essential component of skin assessment, where staff can identify early signs of pressure injuries, rashes, or other conditions that require medical attention. When bathing is deferred for weeks, these clinical observations are also deferred.
The facility's own Director of Nursing acknowledged that if nurses were not assisting with direct resident care, "it would be very difficult for the certified nurse aides to complete their assignments." Yet the Director admitted they had not verified whether nurses were actually providing that assistance.
Infection Control Breakdowns Compound the Risk
The staffing crisis operated alongside separate infection control deficiencies. Inspectors observed two CNAs providing direct care to a resident on enhanced barrier precautions — a resident with a suprapubic catheter and multidrug-resistant organism infection — without wearing required gowns or face masks. The aides emptied and changed catheter bags while wearing only gloves, despite signage outside the room clearly directing staff to use full protective equipment.
In a separate observation, a CNA performing incontinent care on another resident failed to change gloves or wash hands after removing a soiled brief and before applying a clean one. The aide told inspectors they had not been trained to change gloves during this process — contradicting what management stated was standard training.
The facility's Nurse Educator acknowledged that in-service training on enhanced barrier precautions had begun but "did not get to all the employees."
Fly Infestation in Dining Areas and Resident Rooms
Inspectors also documented a persistent fly infestation on Unit 1 that had gone unaddressed for more than two weeks. Flies were observed landing on residents' skin, on food during meal service, and throughout common areas. Rooms with strong urine odors had particularly high concentrations.
One resident told inspectors: "The flies are eating more than I am." Another described "a zillion flies" landing on their face while trying to sleep. Despite residents and family members reporting the issue to staff and administration, no work orders had been submitted to maintenance since July 31, and the Administrator stated they were unaware of any current fly problem.
The infestation originated from gaps around window-mounted air conditioning units that were sealed in late July but evidently not effectively. The facility had no pest control policy on file, and no fly control devices were installed on resident units.
Facility Response and Accountability
The Administrator told inspectors they believed staff should be able to complete all required care with minimum staffing levels "if there was a team approach and they all worked together." However, multiple staff members at every level — from CNAs to the Assistant Director of Nursing — contradicted this assessment.
The facility was also cited for failing to maintain accurate daily staffing reports, a public transparency requirement under New York State regulations. The Scheduling Specialist responsible for the reports stated they did not know their purpose, and the Director of Nursing said updating them with actual numbers "would be a lot of work."
Additional citations included failure to provide prescribed adaptive eating equipment for a resident with Alzheimer's disease and missing immunization consent documentation for multiple residents.
Elderwood at Wheatfield is part of the Elderwood network of post-acute care facilities operating across New York State. The full inspection report, including the facility's plan of correction, is available through the Centers for Medicare and Medicaid Services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elderwood At Wheatfield from 2024-08-14 including all violations, facility responses, and corrective action plans.
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