Elderwood At Lancaster
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
#1 was heard leaving the room by closing the door, Resident #1 was then heard dialing 911, and then the recording stopped.During a telephone interview on 11/04/2025 at 11:32AM, Resident #1 stated they called 911 and stated the staff were rude, they did not feel safe, and they left the faciity on [DATE REDACTED]. Maintenance Assistant #1 yelled and accused them of spitting at Registered Nurse #6 Unit Manager on 09/11/2025 which Resident #1 denied, and that they had to get Resident #1 out of the facility. The police came and an internal investigation was completed. Resident #1 stated the Maintenance Assistant #1's yelling was verbal abuse. During an interview on 11/04/2025 at 2:12PM, the Director of Maintenance #1 stated Maintenance Assistant #1 went into Resident #1's room and told Resident #1 they were there to fix the toilet on the morning of 09/11/2025. There were no work orders for them to be in the room and they had no business being in there. Yelling was anything beyond the normal tone of voice and was verbal abuse.During an
interview on 11/04/2025 at 2:45PM Registered Nurse #4 stated they did not hear or see Resident #1 gesture to spit. Maintenance Assistant #1 should have treated Resident #1 respectfully or let the Nursing Supervisor handle it, but yelling was poor customer service and was verbal abuse. During a telephone
interview on 11/04/2025 at 3:02PM Maintenance Assistant #1 spoke in an inappropriate tone, was boisterous (loud) and stated Registered Nurse #6 Unit Manager told them on 09/11/2025 that Resident #1 was not going to spit on them. The Maintenance Assistant #1 immediately went down to Resident #1's room and told Resident #1 they needed to check the toilet and then confronted Resident #1 not to spit on Registered Nurse #6 Unit Manager stating they repeated it six (6) times. Maintenance Assistant #1 denied speaking inappropriately to Resident #1. They always spoke loud, and was not verbal abuse.During a telephone interview on 11/05/2025 at 9:18AM Director of Nursing #2 stated Maintenance Assistant #1 wanted to protect Registered Nurse #6 Unit Manager. Then they realized the whole conversation was recorded and was angry and upset. The situation was not handled well. They do not think that Maintenance Assistant #1 knew the rules and regulations, that you cannot go into any resident's room and act that way, it was undignified and unprofessional.During an interview on 11/05/2025 at 10:27AM the Director of Social Work #1 stated Resident #1 reported they were verbally assaulted by Maintenance Assistant #1 on 09/11/2025 then Resident #1 played them the audio recording. They heard Maintenance Assistant #1 yelling in an aggressive, loud, and accusatory manner. Residents deserved to be treated with dignity and respect and follow the facility care values which included collaboration, respect, excellence, integrity and accountability. Maintenance Assistant #1's interactions were inappropriate and was verbally abusive.During
a telephone interview on 11/05/2025 at 12:41PM, Registered Nurse #6 Unit Manager stated Resident #1 gestured as if they were going to spit on them, but they did not spit. Maintenance Assistant #1 should have just plunged the toilet, left the room, and should not have spoken to Resident #1 that way. It was disrespectful.During an interview on 11/07/2025 at 1:45PM, the Administrator stated that Maintenance Assistant #1 should not have taken matters in their own hands and let their supervisor handle it. It was determined that Maintenance Assistant #1's behavior was wrong and would not be tolerated and was verbal abuse even if it was unintentional. 10 NYCRR 415.3(d)(1)(vii)
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/23/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Elderwood at Lancaster
1818 Como Park Blvd Lancaster, NY 14086
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Based on interview, and record review conducted during an Abbreviated survey (2615979) the facility did not ensure that all alleged violations involving abuse are reported immediately but not later than 2-hours
after the allegation is made if the events that cause the allegation involve abuse, to the Administrator of the facility and to other officials (including to the State Survey Agency) for one (1) (Residents #1) of three (3) residents reviewed for abuse. Specifically, an allegation of staff to resident verbal and physical abuse was not reported to the New York State Department of Health within the required (2) two-hour timeframe. The finding is: Refer to F 600 Freedom from Abuse and Neglect, scope and severity D The policy titled Abuse Prevention, Identification, Investigation, Protection and Reporting dated 04/30/2024 documented the facility Administrator or designee will report all alleged violations of abuse to state agencies immediately, but no later than (2) two hours after the allegation of abuse, mistreatment; and as required to all other required agencies (e.g., law enforcement, adult protective services, licensing authorities, stated nurse aide registries, etc., when applicable) within specified timeframes. Review of the Minimum Data Set (a resident assessment tool) dated 09/12/2025 documented Resident #1 had intact cognition, was understood and understands. The Internet Quality Improvement and Evaluation System (IQIES) Complaint/Incident Investigation Report received by the New York State Department of Health on 09/20/2025 documented an alleged incident occurred on 09/11/2025 at 8:30 AM. The Administrator was first made aware of the incident
on 09/11/2025 at 10:11 AM. The facility did not report the alleged abuse to the State Agency until 09/15/2025 at 3:18 PM. Review of the facility investigation dated 09/11/2025 revealed a potential altercation between a staff member and the resident occurred on 09/11/2025 at 8:30 AM. Registered Nurse #6, Unit Manager went into Resident #1's room at 8:20 AM and addressed concerns from the night before. During that time, Registered Nurse #6 stated that Resident #1 made a gesture of spitting at them, was rude and swore. Maintenance Assistant #1 entered Resident #1's room at 8:31 AM and told Resident #1 not to spit in Registered Nurse Unit Manager #6's face. Resident #1 called 911 (emergency services). On 09/11/2025 at 9:59 AM a police officer arrived at the facility. Resident #1 alleged that they were threatened and assaulted by Maintenance Assistant #1. Resident #1 alleged that Maintenance Assistant #1 came into their room and repeated multiple times not to spit on Registered Nurse #6 Unit Manager. Resident #1 also alleged that Maintenance Assistant #1 got in their personal space and made contact with their #1's broken ankle and stated Maintenance Assistant #1 was going to beat their (expletive). The facility investigation concluded verbal abuse had occurred. During an interview on 11/07/2025 at 1:35 PM, the Administrator stated they were made aware of the allegation on 09/11/2025 at 9:07 AM when an email complaint was received from Resident #1. The Administrator stated they did not report the alleged verbal and physical abuse to the State Agency until 09/12/2025 at 12:54 PM and should have reported it within (2) two hours as required but somehow forgot. 10NYCRR 415.4(b) (4)
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If continuation sheet
ELDERWOOD AT LANCASTER in LANCASTER, NY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LANCASTER, NY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ELDERWOOD AT LANCASTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.