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 18 of 37 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 19 of 37 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 20 of 37 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 21 of 37 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 22 of 37 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 23 of 37 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 24 of 37 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 0732 Post nurse staffing information every day.

Level of Harm - Potential for 43802 minimal harm Based on observation, interview, and record review conducted during the Standard survey completed on Residents Affected - Many 8/14/24, the facility did not post, on a daily basis, the staff total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. Specifically, the facility's posted staffing was not updated at the beginning of each shift and/or reflected changes in the schedule. Additionally, the facility did not have a policy for completing the DOH Staffing Report.

The finding is:

During observations from 8/8/24 through 8/14/24 from 7:45 AM through 5:00 PM, the DOH Staffing Report was posted at the front desk of the facility, however it did not include an updated total number of actual licensed and unlicensed nursing staff for each shift.

Review of the last 30 days of the documents titled DOH Staffing Report revealed that the forms were not updated with the total number of actual licensed and unlicensed nursing staff for each shift.

During an interview on 8/14/24 at 11:06 AM, the Scheduling Specialist stated they were responsible for completing the DOH Staffing Report and they did not update the report with actual numbers of licensed and unlicensed nursing staff for each shift. They stated they did not know the purpose of the form, but thought it was specifically for the New York State Department of Health to see when they visited the facility. The Scheduling Specialist stated they were not given formal training on how to complete the form but thought there was a policy on it. They stated they would look for the policy.

During an interview on 8/14/24 at 12:24 PM, the Director of Nursing stated they knew the DOH Staffing Report was used to show the public how many staff were in the building, but they didn't think it should be updated to show actual numbers of licensed and unlicensed nursing staff for each shift, because that would be a lot of work, with no call no shows and staff calling off, it sometimes takes a while for supervisors to realize someone didn't show up. They stated they thought there was a policy, and they would look for it.

During an interview on 8/14/24 at 1:00 PM, The Administrator stated they did not know the DOH Staffing Report should be updated to show actual numbers of licensed and unlicensed nursing staff for each shift.

They thought it was to be completed at the beginning of each day. They thought there was a policy for completing the report and they would look for it.

During an interview on 8/14/24 at 3:30 PM the Administrator stated they did not have a policy for the DOH Staffing Report.

10NYCRR 415.13

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 37 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Level of Harm - Minimal harm or 43802 potential for actual harm Based on observation, interview, and record review conducted during a Standard survey completed on Residents Affected - Few 8/14/24, the facility did not ensure that each resident was provided special eating equipment and utensils for residents who need them while consuming meals for one (Resident #85) of one resident reviewed. Specifically, Resident #85 was not provided bowls for solid foods or mugs for liquid beverages as care planned.

The finding is:

The policy and procedure titled Meal Serving-Resident dated 9/24/2018, documented that designated dietary staff will be responsible for ensuring that the necessary items are present at mealtime, or are obtained immediately upon request, for the consumption of food. Nursing staff or other appropriately trained staff will be responsible for fulfilling all non-food requests of residents, feeding of resident if needed, and for other dietary services that are part of the resident's care plan.

Resident #85 had diagnoses that included Alzheimer's disease, unspecified dementia, senile degeneration of brain (loss of intellectual ability of the brain). The Minimum Data Set (a resident assessment tool) dated 7/7/24 documented Resident #85 had severe cognitive impairment. Resident #85 required supervision or touching assistance for eating and helper cues as resident completes activity.

Review of the comprehensive care plan dated 5/17/24 documented that Resident #85 required limited assist while eating, supervision to ensure consumes food and not food packaging and other paper products, mugs for all beverages, bowls for food. Date of initiation was 7/20/23.

Review of the occupational therapy notes dated 9/7/23 documented that Resident #85 was referred for an occupational screening for self-feeding skills, patient demonstrated pouring behaviors, usage of fingers to bring food to mouth instead of utilizing utensils functionally, resulting with patient requiring increased assistance and cueing for self-feeding skills to maximize independence.

Review of an occupational therapy treatment encounter dated 9/8/23, documented that Resident #85 was assessed with bowls to trial an increase in nutritional intake, maximize independence in self-feeding tasks, and decrease pouring behaviors. The writer provided one food at a time presented in bowls with appropriate utensils to promote functional use of utensils and to maximize independence. Resident #85 required moderate verbal cues for initiation to enhance nutritional intake.

Review of an occupational therapy treatment encounter dated 9/22/23 documented that Resident #85 spilled milk in mug, food spillage from plate. Only oatmeal provided in bowls. The writer cleared residents' visual field of cluttered area, while cleaning spillage as resident was noted to utilize utensils and attempted to grab food that had spilled on table tray and themselves. Resident utilized utensils functionally without using fingers to completed self-feeding 90% of the time, as resident noted to use fingers to gather food from spillage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 37 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 0810 During an observation on 8/9/24 at 8:51 AM Resident #85 meal slip stated liquids were to be placed in mugs and food in bowls. Resident #85's orange juice was served in a cup (not a mug) and breakfast meal was Level of Harm - Minimal harm or served on a plate not in bowls. There were no staff members assisting the resident and food had been potential for actual harm pushed off the plate and onto the tray.

Residents Affected - Few During an observation on 8/9/24 at 12:26 PM, Resident #85's lunch was served on a plate and beverages were served in cups, not mugs. There were no staff members assisting the resident and food had been pushed off the plate and onto the tray.

During an observation and interview on 8/12/24 at 12:55 PM, Certified Nurse Aide #1 stated that Resident #85's beverages should be in mugs. They stated the beverages were not in mugs and they were not certain why they were not.

During an observation and interview on 8/12/24 at 12:58 PM, Certified Nurse Aide #2 reviewed the meal slip and stated the meal slip for Resident #85 documented mugs for beverages, Certified Nurse Aide observed cups on their tray. They stated it was important that residents had the correct adaptive equipment for meals to prevent spills and possible burns to the residents' skin if the beverage or food was hot.

During an interview on 8/14/24 at 10:35 AM, the Food Service Director, stated it was the entire kitchens responsibility to ensure the correct adaptive utensils were on trays before they left the kitchen. They stated

they were unaware Resident #85 received their meal tray without the appropriate adaptive equipment on 8/9/24 for breakfast and lunch, and on 8/12/24 for lunch. They stated it was important for the quality-of-life sustainability and ensured the residents maintained as much independence as possible.

During an interview on 8/13/24 3:59 PM with the Director of Rehabilitation stated they completed the assessments to determine what adaptive equipment was needed for meals and the resident's care plan was updated. They stated the bowls were easier to manage for Resident #85 and promoted an increase in independence and food consumption. They stated this resident also had a lot of pouring behavior's and would pour liquids all over their food and was care planned for mugs for all liquids.

During an interview on 8/14/24 9:45 AM, Certified Nursing Assistant #1 stated Resident #85 often spilled food on themselves, and that was why they needed to feed them. They stated supervision with touch assistance meant when the tray arrives, they were trained to look at the tray and ensure adaptive equipment was provided if indicated. They stated they supervised the resident while eating and cued them when not.

They stated they did not notice that Resident #85 was not being provided the correct adaptive equipment but did not give Resident #85 any hot beverages because they might pour it on their food.

During an interview on 8/14/24 at 11:08 AM, the Registered Dietician stated adaptive equipment was provided to residents to increase their independence and to not hinder their progress in getting the appropriate calories and nutrition. The entire kitchen staff should look at the meal slips, and down to the last person who provided the tray to the resident. The staff should have verified the meal slip was accurate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 37 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 0810 During an interview on 8/14/24 at 1:30 PM, the Director of Nursing stated, they expected the staff to review

the meal slips prior to giving the resident their meal tray. This was important to ensure residents had the right Level of Harm - Minimal harm or equipment and to ensure they were safe from hot foods and were able to eat the food provided to them. potential for actual harm 10 NYCRR 415.14 (g) Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 37 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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43802

Residents Affected - Some Based on interview and record review conducted during a Standard survey completed on 8/14/24, it was determined that the facility did not ensure that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized. Specifically, three of five residents (Residents #1, #12, #59) reviewed for complete immunization records had issues with no documented evidence of signed consents or declinations for the 2023 influenza vaccine.

The findings are:

The policy and procedure titled Influenza Immunization (Residents) dated 7/19/22 documented that at the appropriate time of year to determine eligibility for the influenza immunization will be indicated on the Influenza Vaccination Consent Declination Resident form.

1. Resident #1 was admitted to the facility with diagnoses of left sided hemiplegia (paralyzed on the left side), type 2 diabetes mellitus, and asthma. Review of the Minimum Data Set (a resident assessment tool) dated 7/17/24 documented that the resident was cognitively intact, usually understands others, usually understood by others. The Minimum Data Set documented that the resident received an influenza immunization on 10/20/23.

Review of the medication administration record for October 2023 documented the resident received the Flu zone High Dose Quadrivalent influenza vaccine 10/20/23.

Review of the vaccine screening prior to the vaccine dated 10/20/23 documented that Resident #1 was screened prior to receiving the influenza shot.

Review of the update immunization tab in the electronic medical record dated 11/6/23 documented that a consent was obtained for the influenza immunization for Resident #1. Further review of the chronological electronic medical record revealed no scanned copy of the signed consent form for influenza immunizations.

During an interview on 8/14/24 at 10:00 AM, Resident #1 stated that they don't remember if they signed a consent form, nor do they remember if they received an influenza vaccine.

2. Resident #12 was admitted to the facility with diagnoses of type 2 diabetes mellitus and atrial fibrillation (irregular rhythm of the heart). The Minimum Data Set, dated dated dated [DATE REDACTED] documented that the resident is cognitively impaired, understands others, and is understood by others. Further review of the Minimum Data Set documented that the resident received an influenza immunization on 10/20/23.

Review of the medication administration record dated October 2023 documented that the resident received

the influenza vaccination on 10/20/23.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 37 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 0842 Review of the Vaccine Screening Prior to Vaccination form dated 10/20/23 documented that the resident was screened and able to receive the influenza vaccine. Level of Harm - Potential for minimal harm During an interview on 8/14/24 at 9:20 AM, the Assistant Director of Nursing stated that if the resident has capacity, the resident signs the declination or the consent for the influenza immunization. They also stated Residents Affected - Some that the unit clerks would scan the consent forms into the electronic medical record after the vaccine was given. The Assistant Director of Nursing stated that the paper copy goes to medical records after it is scanned.

3. Resident #59 was admitted to the facility with diagnoses of chronic obstructive pulmonary (lung) disease and anxiety. The Minimum Data Set, dated dated dated [DATE REDACTED] documented the resident was severely cognitively impaired, usually understood by others, and usually understands others. Further review of the Minimum Data Set documented that the resident did not receive the influenza immunization.

Review of the immunization tab in the electronic medical record dated 10/19/23 documented that the resident declined the influenza vaccine.

Review of the chronological electronic medical record for declinations of immunizations revealed that there was no scanned copy of a signed influenza immunization declination.

During an interview on 8/14/24 at 9:28 AM, the Director of Nursing stated they typically get the signed consents or declinations at the same time. They stated that once the immunization was completed, it was expected that the unit clerk scanned the document into the electronic medical record. The Director of Nursing stated then the signed paper copy goes to medical records.

During an interview on 8/14/24 at 10:39 AM, the Administrator stated they expected nursing staff to document immunizations accurately and for medical records to make sure signed consents or declinations were scanned into the resident's medical record.

During an interview on 8/13/24 at 3:15 PM, the Unit Clerk stated that once the immunization was given, the form was scanned into the electronic medical record. They stated that they looked through the paper medical records and could not find the signed declinations or consents.

NYCRR 10 415.22(a) (1-4)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 37 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43802 potential for actual harm Based on observation, interview, and record review conducted during a Standard survey completed on Residents Affected - Few 8/14/24, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. for two (Resident #15 and Resident #82) of eight residents reviewed for infection control processes during care. Specifically, Certified Nurse Aide #4 and Certified Nurse Aide #18 did not wear proper personal protective equipment for a resident requiring enhanced barrier precautions with a multidrug resistant organism infection while they emptied a catheter bag (urine collection bag), changed the catheter bag to a leg bag, and transferred the resident to a shower chair (#15). In addition, Certified Nurse Aide #5 did not use proper hand hygiene during incontinent care (Resident #82).

The findings are:

The policy and procedure titled Infection Prevention Control Program dated 7/15/24 documented that staff are responsible to wash their hands frequently especially after handling soiled or contaminated objects,

before and after coming into contact with residents or residents' possessions and are to use protective equipment when coming into contact with a resident on transmission-based precautions.

The Centers for Medicare and Medicaid Services Quality Safety and Oversight memoranda QSO-24-08-NH dated 3/20/24, documented enhanced barrier precautions were indicated for residents with indwelling medical devices even if the resident was not known to be infected or colonized with a multidrug-resistant organism. Examples of indwelling medical devices include urinary catheters. The memo documented enhanced barrier precautions are employed for high contact resident care activities including the care or use of a urinary catheter.

1. Resident #15 was admitted to the facility with diagnoses of multiple sclerosis (an autoimmune disorder that affects the brain, spinal cord, and other nerves) and resistance to multiple antibiotics. The Minimum Data Set (a resident assessment tool) dated 6/19/24 documented Resident #15 was cognitively intact, understands others, and was understood by others. The assessment further documented the resident required substantial assistance for toileting and had a suprapubic urinary catheter (a thin tube inserted into

the bladder to drain urine).

The comprehensive care plan dated 7/1/24 documented the resident required substantial assistance of one staff member with toileting. The comprehensive care plan documented the resident had a neurogenic bladder (a condition where the bladder function is impaired due to nerve damage) that required a suprapubic catheter. Interventions included enhanced barrier precautions.

Review of the Kardex (a guide for resident care) documented that Resident#15 was on enhanced barrier precautions because of their suprapubic catheter.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 37 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 0880 During an observation on 8/13/24 at 8:45 AM outside Resident 15's room, a sign was posted that noted for direct care and transfers, enhanced barrier precautions were needed. Further observation of this sign Level of Harm - Minimal harm or revealed that staff were to wear a gown, gloves, and a mask for direct care of a resident. Outside the room potential for actual harm there was a multi drawer bin that contained face masks, procedure gowns, and gloves.

Residents Affected - Few During a care observation on 8/13/24 at 10:23 AM Resident #15 was being prepared for transfer to a shower chair. Certified Nurse Aide #18 assisted the resident in their bed into a sitting position. Certified Nurse Aide #4 emptied the resident's catheter bag into a container and stated that the resident had approximately 550 milliliters of urine. Certified Nurse Aide #4 emptied the container into the toilet, washed their hands, and applied gloves. Certified Nurse Aide #4 then changed the catheter bag to a leg bag. Certified Nurse Aide #4 placed the catheter bag in Resident #15's bathroom. Certified Nurse Aide #4 washed their hands and changed their gloves. Certified Nurse Aide #18 and Certified Nurse #4 then assisted Resident #15 into a sit to stand lift. Resident #15 was then transferred from their bed into a shower chair. Neither certified nurse aide wore a gown and face mask during these direct care activites.

During an interview on 8/13/24 at 10:35 AM, Certified Nurse Aide #18 reviewed the enhanced barrier precautions sign outside Resident #15's room and stated that they should have worn a mask and a gown when they provided care for Resident #15. Certified Nurse Aide #18 stated that they should have worn protective equipment to prevent any cross contamination with other residents.

During an interview on 8/13/24 at 10:37 AM, Certified Nurse Aide #4 reviewed the enhanced barrier precautions sign outside Resident #15's room and stated that they should have worn a mask, a gown, and protective eyewear because there was a splash risk from changing the catheter bag to a leg bag. Certified Nurse Aide #4 stated there was a risk of cross contamination to other residents or contaminating Resident #15.

During an interview on 8/13/24 at 10:47 AM, the Registered Nurse, Nurse Educator stated that if a resident has an open wound or a tube like a catheter, they expected staff to wear proper protective equipment. They stated that they had started in-services for enhanced barrier precautions for staff but did not get to all the employees. They stated that if there was a sign and a precaution set up outside the resident's room, staff should wear protective equipment.

During an interview on 8/13/24 at 11:07 AM, the Director of Nursing stated they expected their staff to wear personal protective equipment when care was provided to residents on enhanced barrier precautions to prevent contamination.

During an interview on 8/13/24 at 12:19 PM, the Assistant Director of Nursing stated they expected their staff to wear protective equipment when providing care for a resident on enhanced barrier precautions.

During an interview on 8/13/24 at 1:01 PM, the Regional Registered Nurse Infection Preventionist stated that

they would expect the staff to wear any protective equipment like gowns and gloves when they provide direct care to a resident on enhanced barrier protections. They stated that there could be a splash risk when changing a catheter bag to a leg bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 37 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 0880 2. Resident 82 was admitted to the facility with diagnoses of hemiplegia (paralysis on one side of the body) and dysphagia (a condition with difficulty in swallowing). The Minimum Data Set, dated dated dated [DATE REDACTED] Level of Harm - Minimal harm or documented that Resident #82 was cognitively intact, understands others, and was understood by others. potential for actual harm The Minimum Data Set documented the resident required maximal assistance for toileting of one staff member and always incontinent of urine. Residents Affected - Few

The comprehensive care plan revised on 4/23/24 documented Resident #82 was a maximal assist of one staff member for toileting hygiene.

The Kardex documented the resident was always incontinent of urine and needed incontinent care every two to four hours or as needed.

During an observation of incontinent care on 8/13/24 at 8:15 AM, Certified Nurse Aide #5 put a plastic barrier

on the residents over the bed table and one on the floor next to the resident's bed. Certified Nurse Aide #5 washed their hands, put on gloves, and brought out wet washcloths and placed them onto the barrier on the over the bed table. They raised the bed of Resident #82 to perform incontinent care. Certified Nurse Aide #5 removed Resident #82's incontinence brief which was moderately wet with urine and placed the wet brief on

the plastic barrier on the floor. Certified Nurse Aide #5 did not change their gloves or wash their hands after removing the wet brief. They then cleansed the front genital area of Resident #82 with one washcloth that had body wash on it then took another wet washcloth from the over the bed table and wiped off the body wash from the front genital area. They then dropped the washcloths onto the plastic barrier on the floor. Certified Nurse #5 then dried the resident with a towel. They folded the used part of the towel and placed the used towel on the over the bed table. The did not change gloves or wash hands after cleaning the front genital area. Certified Nurse Aide #5 asked Resident #82 to turn to their side so they could wash their buttocks and rear genital area. Certified Nurse Aide #5 took a clean washcloth with body wash on it and cleansed the resident's buttocks and rear genital area; wiped off the soap with another washcloth; and patted dry. Certified Nurse Aide #5 put all the used washcloths and towels on the plastic barrier on the floor. They did not change gloves or wash their hands. Certified Nurse Aide #5 then put a new brief on the resident and straightened out Resident #82 nightgown. Certified Nurse Aide #5 then discarded the used linens.

During an interview on 8/13/24 at 8:31 AM, Certified Nurse Aide #5 stated they were not trained to change gloves or wash hands after changing a wet brief. They stated that there could be some contamination if you didn't wash your hands and change your gloves after changing a wet brief.

During an interview on 8/13/24 at 10:47 AM, the Registered Nurse, Nurse Educator stated they expected staff when performing incontinence care for staff to wash their hands and change their gloves after handling

a wet brief and before putting on a new brief. They stated staff were taught to do this.

During an interview on 8/13/24 at 11:07 AM, the Director of Nursing stated they expected their staff to wash their hands and change their gloves after changing a brief and before they put a new brief on the resident.

During an interview on 8/13/24 at 1:01 PM, the Regional Registered Nurse Infection Preventionist stated they expected the staff to change their gloves and wash their hands after a staff member changed a wet brief and

before they put a clean one on a resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 37 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 0880 NYCRR 10 415.19(b)(4)

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 37 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43802 potential for actual harm Based on observation, interview, and record review during the Standard survey completed on 8/14/24, the Residents Affected - Some facility did not maintain an effective pest control program so that the facility was free from insects for one (Unit 1) of three resident units. Specifically, flies were observed in resident rooms, dining rooms and common (lounge) area on Unit 1.

The findings are:

Refer to F 584 Safe clean and comfortable environment.

Facility was unable to provide a policy and procedure for pest control.

Review of work order dated 7/29/24, Resident room [ROOM NUMBER], documented the resident's family stating flies were coming in from around open, air conditioner. Work order indicated work order completed 7/29/24, seal around air conditioner.

Review of work order dated 7/31/23, Resident Room's #100, #106, #107 noted reports of flies coming in from outside through gaps left by air conditioners. Work order documented completed, all three rooms sealed up air conditioners, done.

Review of pest company National Accounts Service Report dated 6/20/24 and 7/18/24 commented fly lights were serviced. No fly lights on resident units.

During an observation on 8/8/24 at 11:42 AM, 11:46 AM and 11:48 AM revealed multiple live small flies on

the Side B lounge area landing on residents sitting in that area. Resident #45 heard saying Get that fly out of here, and Kill that fly.

During an observation on 8/8/24 at 11:46 AM, Resident room [ROOM NUMBER] had strong urine odor and live small flies present. There was a resident in bed and flies were observed landing on the resident's bare skin of their leg and on the wheelchair in the room. At the time of the observation the resident stated there were flies all the time, especially in the dining room. The resident stated flies were terrible and were germ carriers. They stated they have reported the flies to staff and haven't heard back.

During an observation on 8/8/24 at 12:31 PM and 12:48 PM, multiple small flies were observed in the Private dining room during meal service. Flies landed on resident's food.

During observation on 8/9/24 at 10:42 AM Resident room [ROOM NUMBER] had a strong odor of urine, and live small flies were observed in the room. An interview this time with the resident that resided in the room stated there have been a zillion flies the last week or two. They stated when they are trying to sleep, they land on their face, they try to swat them away, but they were too fast for them. The resident stated they believed the staff were aware because they yell at the flies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 37 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 0925 During an interview on 8/12/24 at 11:37 AM, an visiting family member of Resident #63 on Unit 1 stated there have been a lot of flies. They stated it has been over two weeks and that they have spoken to the Level of Harm - Minimal harm or Administrator about it. They stated initially they thought it was from the gap between the window and air potential for actual harm conditioning units the facility put in, but it's been over 2 weeks. During the interview, the family member swatted a fly away with their hand that was flying in front of their face. They stated the flies were unsanitary Residents Affected - Some and that the unit smelt like urine.

During an observation and interview on 8/12/24 at 5:35 PM, the Unit 1 Main Dining room had multiple flies, flying around residents' food while they were eating. Residents were observed swatting at flies while they were eating their food. Resident #26 stated, the Flies are eating more than I am.

During an observation on 8/13/24 at 1:38 PM, there were a few flies flying around an unidentified resident consuming a sandwich in the Side B lounge area of Unit 1. The resident was unable to be interviewed. There was a strong urine odor presents in lounge area.

During an interview on 8/13/24 at 1:47 PM, Licensed Practical Nurse #2 stated there had been a fly presence since they placed the air conditioning units in the resident's rooms. Licensed Practical Nurse #2 stated the air conditioning units were not sealed all the way around and felt the fly situation was circumstantial due to the air conditioning units. They stated flies were pests and were gross. They stated maintenance should be aware but wasn't sure if a work order had been submitted for the flies.

During an interview on 8/14/24 at 8:26 AM, Registered Nurse #1, Unit Manager, stated there has been an increase in flies on Unit 1 since the air conditioning units were placed, at least two weeks ago. They stated maintenance and administration were aware and working on it. They stated the presence of flies was not homelike and this was there home. Additionally, they stated the urine odor may contribute to the flies.

During an interview on 8/14/24 at 8:32 AM, Maintenance Assistant stated they have not received any work orders related to flies. They stated they were unaware of any fly issue on Unit 1. They stated resident units should be pest free and didn't think there should be a presence of flies on the unit. They stated flies were unsanitary; source of flies needed to be determined and eliminated. Additionally, they stated they would expect staff to notify the maintenance department of issues with pests.

During an interview on 8/14/24 at 8:40 AM, Housekeeping Aide stated they have observed flies on the unit but haven't informed maintenance of the flies.

During an interview on 8/14/24 at 8:47 AM, the Director of Facility Management stated they were unaware of any fly concerns in the last 2 weeks. They stated they had received a few calls related to gaps after air conditioning units were placed that were addressed. They stated they still wouldn't expect flies to be present today on unit from over 2 weeks ago. They stated flies shouldn't be to a point of swatting away, the environment should be comfortable and clean. They stated everyone has access to the work order system, and they would expect staff to inform them of fly issues. Additionally, they stated they have never had to call

the exterminator related to flies on the unit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 37 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 0925 During an interview on 8/14/24 at 8:58 AM, Certified Nursing Assistant #6 stated there has been an increase

in flies on Unit 1 in the resident rooms but mostly in the lounge area and dining rooms. They stated they Level of Harm - Minimal harm or reported it to a nurse last week and was told by the nurse it was being taken care of. Certified Nursing potential for actual harm Assistant #6 stated the flies were gross, and not sanitary where residents were trying to eat their food.

Residents Affected - Some During an additional interview on 8/14/24 at 11:58 PM, Director of Facility Management stated they had not received any work orders related to flies since 7/31/24 and those work orders were addressed.

During an interview on 8/14/24 at 1:23 PM, Administrator stated they weren't aware of there being a fly concern currently on Unit 1. They stated they would expect that if an issue were being identified staff would let maintenance and housekeeping know right away, so something can be done about it.

10NYCRR 415.29(j)(5)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 37 335790