Elderwood At Wheatfield

F-F561 Resident Choices, scope and severity = D

1. The Facility assessment dated [DATE REDACTED], documented the facility's bed capacity was 123 and their average daily census at the time of the assessment was 107. The facility assessment documented the minimum number of staff required to meet the needs of the residents was determined based on total resident population, resident acuity, and facility physical plan layout. The master staffing plan documented the minimum staff required for each unit and each shift was: 6:00 AM to 2:00 PM, 1 Nurse and 2 Certified Nurse Aides; 2:00 PM to 10:00 PM, 1 Nurse and 2 Certified Nurse Aides; 10:00 PM to 6:00 AM, 1 Nurse and 1 Certified Nurse Aide.

The policy and procedure titled Labor Disruption, dated 6/19/23 documented, in the case of a labor shortage such as, unavailability of appropriate/qualified persons to work, the Nursing Supervisor would notify the Administrator and other administrative personnel and they would mobilize staff and services from outside sources: off duty staff, health care agencies. The Director of Nursing would be required to enlist the help from departments other than nursing.

The daily staffing sheets, reviewed from 7/8/24 through 8/14/24, documented the facility did not meet their minimum number of staff on the following dates:

-7/14/24 10:00 PM to 6:00 AM, down 1 Certified Nurse Aide

-7/22/24 6:00 AM to 2:00 PM, down 1 Certified Nurse Aide

-8/1/24 6:00 AM to 2:00 PM, down 0.5 Certified Nurse Aide

-8/7/24 6:00 AM to 2:00 PM, down 0.5 Certified Nurse Aide, 2:00 PM to 10:00 PM down 0.5 Certified Nurse Aide

-8/9/24 2:00 PM to 10:00 PM, down 1 Certified Nurse Aide

-8/11/24 2:00 PM to 10:00 PM, down 0.5 Certified Nurse Aide

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 17 335790 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335790 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Elderwood at Wheatfield 2600 Niagara Falls Boulevard Niagara Falls, NY 14304

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 0725 -8/12/24 6:00 AM to 2:00 PM, down 0.5 Certified Nurse Aide

Level of Harm - Minimal harm or -8/13/24 6:00 AM to 2:00 PM, down 0.5 Certified Nurse Aide potential for actual harm

During an interview on 8/14/24 at 11:06 AM, the Scheduling Specialist stated they thought they had been Residents Affected - Many meeting their minimum staffing levels. After reviewing the dates listed above, the Scheduling Specialist stated they did not meet their minimum staff levels on those dates. The Scheduling Specialist stated their ideal staffing level would be 5 Certified Nurse Aides and 2 nurses on every unit for day and evening shifts, and 2 nurses and 2 Certified Nurse Aides for night shift.

During an interview on 8/14/24 at 12:24 PM, the Director of Nursing #1 stated staff made them aware they could not get all their work done because of staffing. They stated they had developed a plan that nurses were to assist with resident care to ensure all residents care plans were followed when there were only 2 aides scheduled and they expected certified nurse aides to report to their Unit Manager if they were unable to provide care according to the care plans. The Director of Nursing #1 stated if the nurses were not helping with care, then it would be very difficult for the certified nurse aides to complete their assignments and provide care to all residents according to the care plans. They stated they had not verified if the nurses were assisting the aides when the facility had 2 aides scheduled on each unit on the day shift. The Director of Nursing #1 stated managers told them they had complaints from family and residents about not getting their requests met in a timely manner, and they complained it was because of staffing. The Director of Nursing #1 stated they were aware there were times they did not meet their minimum staffing levels. They themselves have come in to work as the supervisor when a nurse was unavailable.

During an interview on 8/14/24 at 1:00 PM, the Administrator stated they felt the staff should be able to get all their work done and follow the residents' care plans with their minimum staffing levels if there was a team approach and they all worked together, such as nurses and therapists assisting with resident care. They expected the nursing staff to provide care to all residents according to their care plans and if they were unable to follow the care plan, they would expect the nursing department to let them know. The Administrator was aware they had not met their minimum staffing levels for the listed dates. They stated that management would have stepped up to help the staff complete their work.

2. Review of the Resident Council minutes dated 6/6/24, revealed that several residents from Unit 2 reported concerns of late get ups and the nursing department was to be invited to the July 2024 meeting. During the meeting on 7/2/24 the council was updated on the concern from June. The completed concern form for the reported concerns from the 6/6/24 meeting documented that the late get up concern was shared by 4 of 10 residents who attended the meeting, and the specific concern was that recently, they had not been gotten up until after lunch. The response, documented by the Director of Nursing, was: Director of Nursing to talk with staff and unit managers to re-enforce early get ups to prevent any delays of morning get ups for all residents.

During the meeting on 8/1/24 residents were informed by the Administrator that many staff were being cross trained to help, when there were shortages in various departments, to ensure the best possible care was provided. The residents did not respond.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 17 335790 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335790 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Elderwood at Wheatfield 2600 Niagara Falls Boulevard Niagara Falls, NY 14304

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 0725 During Resident Council interviews on 8/9/24 from 11:09 AM to 12:00 PM, residents stated that low staffing caused the staff to ignore residents and shut off call lights and say they would be right back, but staff did not Level of Harm - Minimal harm or return. Residents had to re-activate their call lights to get assistance from staff. One resident reported they potential for actual harm sometimes get passed over in the mornings, when staff were assisting residents with getting up. The resident required the assistance of two staff with personal care and transfers. Residents also reported they Residents Affected - Many could not get assistance with getting out of their wheelchair during the day, could not get their water and ice pitchers filled and experienced long waits for anything they may have requested.

3. Observation and interviews with residents, Ombudsman, family members and staff revealed the following:

During an interview on 8/8/24 at 9:17 AM, Resident # 91 stated the facility did not have enough staff and some nights they had to wait up to an hour for pain medication.

During an observation and interview on 8/8/24 at 10:13 AM, Resident #76 was observed in bed with a gown

on and stated they had not been out of bed yet today and didn't like eating breakfast in bed. Resident #76 stated the facility did not have enough staff, therefore they had to eat breakfast in bed 1 to 2 times a week and they didn't like it.

During an interview on 8/8/24 at 10:26 AM, Certified Nurse Aide #19 stated the facility didn't have enough staff, and often the unit was scheduled with 2 aides. Today the unit had a census of 40, therefore they had 20 residents on their assignment. Certified Nurse Aide #19 stated there was not enough staff to provide all

the care necessary according to the resident's care plans such as showers, incontinent care, getting residents out of bed according to their preferences and toileting. They stated often residents waited up to an hour for toileting and then sometimes they were incontinent because they couldn't provide the care timely.

During an additional interview on 8/8/24 at 11:05 AM, Certified Nursing Assistant #19 stated sometimes residents were not gotten out of bed the entire day shift because of short staffing and they didn't know if the residents left in bed were gotten out of bed on the evening shift. They stated some nurses would help with resident care and others would not. They stated Resident #76 was not provided care today until 10:45 AM because they did not have time. They stated Licensed Practical Nurse #8 knew they couldn't provide care according to the care plan for all residents.

During an observation and interview on 8/8/24 at 11:10 AM, Resident #82 was observed being transferred out of bed by Certified Nurse Aide #19 with a stand lift, Resident #82's brief was saturated with urine and feces oozing out of the edges of the brief, the bed sheet and draw sheet were saturated with urine and feces. Resident #82 stated they had been waiting for a while but would not provide specifics of how long. Certified Nurse Aide #19 stated they had started at 6 AM today and that was the first time they had been able to provide care to Resident #82 because they were short staffed.

During an interview on 8/8/24 at 11:13 AM, Activities Aide #1 stated they were also a Certified Nurse Aide and helped with resident care because of short staffing. They stated they often couldn't do activities with the residents because they were busy helping the Certified Nurse Aides.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 17 335790 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335790 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Elderwood at Wheatfield 2600 Niagara Falls Boulevard Niagara Falls, NY 14304

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 0725 During an observation and interview on 8/8/24 at 11:40 AM, Resident #56 was lying in bed. They stated they were waiting for staff to get them out of bed. During an additional interview on 8/9/24 at 8:48 AM, Resident Level of Harm - Minimal harm or #56 stated that they were lucky if they got a shower once a week. They stated they like to be out of bed by potential for actual harm 10:00 AM and they mostly never were. Resident #56 stated they got out of bed right before lunch on 8/8/24 and they minded. They stated there was usually only one certified nurse aide for that wing of the unit. Residents Affected - Many

During an interview on 8/8/24 at 11:48 AM, Certified Nurse Aide #1 stated they had been working at the facility for thirty-three years and staffing was currently at its worst. They stated they were uncertain if they were offering sign on bonuses, but they were offered $100.00 to stay late. They often declined due to exhaustion.

During an interview on 8/8/24 at 11:52 AM, Resident #86 stated the facility did not have enough staff to provide them with two showers a week and they received only one shower since they were admitted last month.

During a family interview on 8/8/24 at 12:22 PM, Resident #32's spouse stated the facility did not have enough staff because the resident often had to wait up to an hour to be changed after having a bowel movement. They stated that the staff were very good, they just didn't have enough help, and it was not intentional, but it was neglect due to insufficient numbers.

During a telephone interview on 8/8/24 at 12:29 PM, the Ombudsman stated they had received concerns recently about short staffing, and that it's gotten worse. The Ombudsman did not reveal resident information as they did not give them permission to act on the information.

During an observation and interview on 8/8/24 at 12:38 PM, a family member was assisting Resident #46 with their meal and stated there just wasn't enough help. They stated there weren't enough aides to care for

the residents and a family member was often there to assist the resident with their meals.

During an interview on 8/8/24 at 1:18 PM, Certified Nurse Aide #3 stated they were not always able to get all their work done and follow the resident's care plans, including showers and changing incontinent residents every 2- 4 hours, because they did not have enough staff, they were often the only aide on the rehab unit for that shift. They stated, if they couldn't get something done, they passed it on to the next shift and told the nurse. Certified Nurse Aide #3 stated that the nurses would help if they had time, but with only one nurse on

the unit they were usually unable to help. They stated that if they had 3 or 4 aides, on Unit 4, they would be able to get all their work done and complete their documentation as they should.

During an interview on 8/8/24 at 4:31 PM, Resident #13 stated they were not getting their scheduled showers

on Fridays mornings due to low staffing numbers. They stated that the staff did not offer to give them a shower at a different time or different day, and they wanted a shower at least once a week. Resident #13 also stated there were times they were not out of bed or back to bed as they preferred due there not being enough staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 335790 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335790 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Elderwood at Wheatfield 2600 Niagara Falls Boulevard Niagara Falls, NY 14304

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 0725 During an interview on 8/8/24 at 5:05 PM, Certified Nurse Aide #4 stated Unit 2 was usually staffed with just two aides on the day shift. They stated that once a month the units would hold town hall meetings and staff Level of Harm - Minimal harm or would express their low staffing concerns. Certified Nurse Aide #4 stated they got Resident #56 out of bed potential for actual harm prior to the resident's lunch, and they knew Resident #56 requested to be gotten out of bed earlier than that.

They stated they could not get Resident #56 out of bed at their preferred time because there were only two Residents Affected - Many aides on the floor. Certified Nurse Aide #4 stated they did not provide any showers that were scheduled on 8/8/24 due to staffing issues, passing trays and they were still getting residents out of bed. During a further

interview on 8/13/24 at 4:11 PM, Certified Nurse Aide #4 also stated they had not been able to get to Resident #55's shower due to staffing.

During an interview on 8/9/24 at 7:55 AM, Resident #1 stated sometimes they were not gotten out of bed

before breakfast, and they wanted to be. They were not provided showers two times a week per their preference and sometimes their showers were skipped an entire week because there was not enough staff.

During an additional interview on 8/12/24 at 10:47 AM, Resident #1's Health Care Proxy stated the resident did not receive their showers as scheduled and sometimes they did not get a shower for a week or longer because there was not enough staff.

During an interview on 8/9/24 at 12:02 PM, Resident #15 stated they were usually late getting out of bed for breakfast due to low staffing. They stated they needed to be out of bed around 8:30 AM to eat their meal in

the dining room and were usually not out of bed until 9:30 AM. Resident #15 stated that did not always get their scheduled shower on Tuesdays and Saturdays and staff did not have time to wash them when they got them up for the day. Resident #15 stated there were never any staff on Saturdays to give them their showers. They stated that staff would, at times, enter their room, turn off their call light and then not return to assist them.

During an interview on 8/12/24 at 11:39 AM, Resident #89's family member stated the biggest problem with

the understaffing was when residents had to go to the bathroom. Resident #89 was a two assist, and the aide would have to find someone to help, and that could take hours.

During a telephone interview on 8/12/24 at 4:38 PM, Certified Nurse Aide #7 stated when they worked the 2:00 PM-10:00 PM shift there were usually just two aides on Unit two and they did not have time to complete all their work. Certified Nurse Aide #7 stated they told the nurses and the unit manager they could not complete all their work due to low staffing. Certified Nurse Aide #7 stated they normally worked Unit one on

the 10:00 PM-6:00 AM shift with no other scheduled aide. They stated they usually only have time to get one incontinent care round completed because they would need to be with the residents that were having behaviors. Certified Nurse Aide #7 stated they let the nurse, or the supervisor know they could not complete all their duties, and many times the nurse was also the building supervisor.

During an interview and observation on 8/12/24 at 5:31 PM, Resident #55 was out of bed in their wheelchair visiting with their family member. Resident #55's family member stated that it had been three weeks since

the resident had a shower.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 335790 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335790 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Elderwood at Wheatfield 2600 Niagara Falls Boulevard Niagara Falls, NY 14304

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 0725 During an interview on 8/13/24 at 1:04 PM, Licensed Practical Nurse #9 stated they were the only nurse on their unit that shift, and they knew they would not be able to complete all their work. They stated that some of Level of Harm - Minimal harm or the treatments wouldn't get done but they would tell their manager before they left. They stated they were potential for actual harm asked to stay for the evening shift today and if they refused, they might get mandated to stay. They stated

they would make sure all the medications were passed before they left, but they could not stay. They stated Residents Affected - Many they felt that the residents were being unintentionally neglected because of the lack of staff.

During an interview on 8/13/24 at 1:19 PM, Certified Nurse Aide #10 stated that if a resident's shower was not signed off in the electronic medical record, then it was not completed. They stated when they worked alone on one wing of Unit two, they could not get all their work done. They stated they prioritized incontinent care over showers and let the nurses and unit manager know what work was not completed.

During a telephone interview on 8/13/24 at 1:28 PM, Certified Nurse Aide #9 stated they worked on Unit two from 6:00 AM-7:00 PM and when they were the only aide on a wing, they did not complete their showers due to staffing. They stated they would either let their nurses know or report off to the oncoming shift which showers did not get done.

During an interview on 8/13/24 at 1:45 PM, Certified Nurse Aide #18 stated they could not get all their work done when there were only two aides on unit two. They stated there were times when they were the only aide working the whole unit with two nurses. Certified Nurse Aide #18 stated the nurses knew they could not get their work done and they were told to do their best to keep the residents dry and fed.

During an interview on 8/14/24 at 8:32 AM, Certified Nurse Aide #4 stated that staffing was not where it should be in the facility. They stated that getting the residents up, providing incontinent care and meals were their priorities, but they were not always able to follow the care plans and get everything done. Certified Nurse Aide #4 stated that the residents could be being unintentionally neglected due to the lack of staff. They stated they were asked to come in for extra shifts at least a couple times every week.

During interviews on 8/14/24 at 9:33 AM and 11:24 AM, the Acting Unit Manager/Assistant Director of Nursing stated the facility would benefit from more staff. They stated that staff did tell them they couldn't get their work done because they were short staffed. They stated when staff came to them, they would try to help them with whatever tasks they can't complete. The Acting Unit Manager/Assistant Director of Nursing stated they thought the minimum staff should be 2 nurses per unit and at least 3 aides. They stated 2 nurses and 2 certified nursing assistants for 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 knew there was not enough staff to provide showers to the residents when there were only 2 certified nursing assistants scheduled. They stated it was the Administrator's responsibility to ensure there was enough staff to provide care to all residents according to the care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 335790 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335790 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Elderwood at Wheatfield 2600 Niagara Falls Boulevard Niagara Falls, NY 14304

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 0725 During an interview on 8/14/24 at 9:51 AM, Certified Nurse Aide #1 stated there was not enough staff, and

the unit manager on Unit 1, had to be the cart nurse as well as perform their other duties. They stated there Level of Harm - Minimal harm or were only two aides, on Unit 1, with approximately 20-24 residents per aide. They stated that was not potential for actual harm enough staff to get their work done. Certified Nurse Aide #1 stated it was the facility's responsibility to ensure

they had enough staff to provide adequate care to the residents. Residents Affected - Many

During an interview on 8/14/24 at 10:17 AM, the Registered Nurse #2 Unit Manger (on Unit 4) stated that

they were aware staff were not always able to get their work done, and at times they themselves have given

a resident a shower. When they have staff call off, they call other staff and offer bonuses. They felt their minimum staff on their unit should be 2 nurses and 2 aides. Registered Nurse #2 Unit Manager stated the Director of Nursing and the Administrator knew they needed more staff. They stated they sometimes stayed late and worked the unit when they didn't have enough staff.

During an interview on 8/14/24 at 10:39 AM, Licensed Practical Nurse #7 stated at times for eight hours of their shift, there was no other nurse working with them on the unit. They stated they would give medications and do vital signs, but they have to prioritize their treatments to just complete the worst ones. Licensed Practical Nurse #7 stated they usually only work with two certified nurse aides and the certified nurse aides cannot get to all of their showers and cannot get all the resident out of bed for the day. Licensed Practical Nurse #7 stated it was especially hard on the weekends because if they were having a resident with behaviors, they do not have enough staff to sit with that resident.

During an interview on 8/14/24 at 12:19 AM, Certified Nurse Aide #9 stated they often work with only 2 aides

on Unit 2, therefore they had an assignment of 19 - 21 residents and were unable to provide care according to the care plan for all residents because there was not enough staff; they reported it to the nurses, and they stated the facility has had meetings concerning the staffing shortages. They stated it was the Administrator's responsibility to ensure there was enough staff for the resident population.

415.13 (a)(1)(i)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 335790