Cycle 1
Health 2025-04-18 · Fire 2025-04-18
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Amherst, NY
Elderwood At Amherst
3-star overall rating with 2-star inspections with abuse icon flag with $25,262 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
4459 Bailey Ave, Amherst, NY
(716) 835-2543
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
92
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Elderwood
Operator or chain grouping
Approved since
1967-01-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.97
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.29
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,615
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.25
Composite VBP score used to determine payment impact.
Payment multiplier
1.0102
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.10
Baseline 19.23% · Performance 18.61% · Measure score 6.10 · Achievement 6.10 · Improvement 2.33
Healthcare-associated infections
7.65
Baseline 4.42% · Performance 5.55% · Measure score 7.65 · Achievement 7.65 · Improvement 0
Total nurse turnover
4.94
Baseline 45.57% · Performance 43.48% · Measure score 4.94 · Achievement 4.94 · Improvement 0.51
Adjusted total nurse staffing
3.41
Baseline 3.55 hours · Performance 4.05 hours · Measure score 3.41 · Achievement 3.41 · Improvement 1.74
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.27% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 8.41% · Lower 95% interval 6.75% |
| Discharge to community | 56.64% |
50.57%
6.1 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 51.24% · Lower 95% interval 46.98% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.29% |
95.27%
About the same
|
Numerator 81 · Denominator 85 |
| Falls with major injury | 1.18% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 85 |
| Discharge self-care score | 56.72% |
53.69%
3 pts better
|
Numerator 38 · Denominator 67 |
| Discharge mobility score | 56.72% |
50.94%
5.8 pts better
|
Numerator 38 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 2.35% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 85 · Adjusted rate 2.55% |
| Healthcare-associated infections requiring hospitalization | 5.55% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 0% · Lower 95% interval 2.73% |
| Staff COVID-19 vaccination coverage | 3.33% |
8.2%
4.9 pts worse
|
Numerator 5 · Denominator 150 |
| Staff flu vaccination coverage | 31.79% |
42%
10.2 pts worse
|
Numerator 62 · Denominator 195 |
| Discharge function score | 52.24% |
56.45%
4.2 pts worse
|
Numerator 35 · Denominator 67 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 98.21% |
96.28%
1.9 pts better
|
Numerator 55 · Denominator 56 |
| Resident COVID-19 vaccinations up to date | 23.26% |
25.2%
1.9 pts worse
|
Numerator 10 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 69.7% |
91.2%
21.5 pts worse
|
93.4%
23.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 67.2% · Q2 66.7% · Q3 73.9% · Q4 70.4% · 4Q avg 69.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
95.3%
1.7 pts better
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.0%
0.4 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 2.9% · Q4 7.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
18.5%
15.8 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.6% · Q3 3.1% · Q4 4.4% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
6.1%
3.2 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 1.8% · Q4 5.5% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.7% |
13.5%
2.8 pts better
|
19.6%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 10.0% · Q3 10.1% · Q4 11.3% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.0% |
14.8%
7.2 pts worse
|
16.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 23.5% · Q3 21.6% · Q4 21.2% · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.8% |
15.1%
1.7 pts worse
|
16.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 20.9% · Q3 7.0% · Q4 31.2% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.8% |
15.5%
7.3 pts worse
|
14.9%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 28.1% · Q3 19.4% · Q4 29.9% · 4Q avg 22.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.6%
0.4 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
1.4%
0.1 pts worse
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 0.0% · Q4 2.8% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.6% |
20.8%
4.8 pts worse
|
19.8%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 37.1% · Q3 23.6% · Q4 19.5% · 4Q avg 25.6% |
| Percentage of long-stay residents with pressure ulcers | 14.1% |
6.9%
7.2 pts worse
|
5.1%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 13.2% · Q3 14.8% · Q4 12.0% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.3% |
76.7%
23.4 pts worse
|
81.7%
28.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 42.1% · Q2 56.2% · Q3 67.3% · Q4 48.7% · 4Q avg 53.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
9.7%
3.6 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 6.5% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.7% |
78.8%
21.1 pts worse
|
79.7%
22 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
20.6%
0.9 pts worse
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 22.6% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-15 · Fire 2023-12-15
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-05-03 · Fire 2022-05-03
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-18
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-12
E · Potential for more than minimal harm
2023-12-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-15
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-02-01
D · Potential for more than minimal harm
2022-05-03
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-06-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-01-30
D · Potential for more than minimal harm
2025-04-18
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-04-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-04-18
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-01-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-12
J · Immediate jeopardy
2023-12-15
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-01
E · Potential for more than minimal harm
2022-05-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-06-27
D · Potential for more than minimal harm
2022-05-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-06-27
D · Potential for more than minimal harm
2022-05-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-06-27
D · Potential for more than minimal harm
2022-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-27
Penalties and ownership
What sits behind the stars
$25,262
2023-12-15
Fine
Fine · fine $25,262
Fine
Ownership
Cole, Warren
5% Or Greater Direct Ownership Interest · Individual
Rubin, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Cole, Warren
Operational/Managerial Control · Individual
Harris, Ann
W-2 Managing Employee · Individual
Rubin, Jeffrey
Operational/Managerial Control · Individual
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