Cycle 1
Health 2025-06-04 · Fire 2025-06-04
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Hamburg, NY
Elderwood At Hamburg
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
5775 Maelou Drive, Hamburg, NY
(716) 648-2820
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
166
Certified beds
Average residents
144
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Elderwood
Operator or chain grouping
Approved since
1985-01-21
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
0.57
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.73
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.02
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.50
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
2.95
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,145
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.84
Baseline 20.06% · Performance 19.19% · Measure score 4.84 · Achievement 4.84 · Improvement 2.38
Healthcare-associated infections
3.69
Baseline 5.39% · Performance 6.73% · Measure score 3.69 · Achievement 3.69 · Improvement 0
Total nurse turnover
0
Baseline 56.76% · Performance 63.36% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.10 hours · Performance 3.07 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.14% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 133 · Observed rate 12.03% · Lower 95% interval 7.73% |
| Discharge to community | 46.07% |
50.57%
4.5 pts worse
|
No Different than the National Rate · Eligible stays 142 · Observed rate 38.73% · Lower 95% interval 39.56% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99% |
95.27%
3.7 pts better
|
Numerator 99 · Denominator 100 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 100 |
| Discharge self-care score | 46.84% |
53.69%
6.8 pts worse
|
Numerator 37 · Denominator 79 |
| Discharge mobility score | 55.7% |
50.94%
4.8 pts better
|
Numerator 44 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 3% |
2.29%
0.7 pts worse
|
Numerator 3 · Denominator 100 · Adjusted rate 3.41% |
| Healthcare-associated infections requiring hospitalization | 6.73% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 6.52% · Lower 95% interval 4.19% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 27% |
42%
15 pts worse
|
Numerator 54 · Denominator 200 |
| Discharge function score | 55.7% |
56.45%
0.8 pts worse
|
Numerator 44 · Denominator 79 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 19 · Denominator 20 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 55 · Denominator 55 |
| Resident COVID-19 vaccinations up to date | 28.57% |
25.2%
3.4 pts better
|
Numerator 14 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.0% |
91.2%
1.2 pts worse
|
93.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 69.9% · Q2 97.3% · Q3 97.2% · Q4 95.6% · 4Q avg 90.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
95.3%
2.3 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.0%
3.2 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 8.8% · Q3 6.4% · Q4 3.5% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
18.5%
17.5 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 2.0% · Q4 1.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
6.1%
1.1 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.9% · Q3 3.1% · Q4 4.7% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
13.5%
5.7 pts worse
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 18.2% · Q3 20.4% · Q4 18.5% · 4Q avg 19.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
14.8%
3.9 pts better
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 10.8% · Q3 10.6% · Q4 12.2% · 4Q avg 10.9% · 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 | 24.4% |
15.1%
9.3 pts worse
|
16.3%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.7% · Q2 23.1% · Q3 23.4% · Q4 22.3% · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.1% |
15.5%
4.6 pts worse
|
14.9%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 22.6% · Q3 19.4% · Q4 24.5% · 4Q avg 20.1% · 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 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.4%
1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.3% |
20.8%
13.5 pts worse
|
19.8%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 42.2% · Q3 22.8% · Q4 38.3% · 4Q avg 34.3% |
| Percentage of long-stay residents with pressure ulcers | 9.2% |
6.9%
2.3 pts worse
|
5.1%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 11.4% · Q3 7.2% · Q4 10.7% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
76.7%
19 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.4% · Q2 94.7% · Q3 95.1% · Q4 98.8% · 4Q avg 95.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
9.7%
0.6 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 9.0% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.2%
0.1 pts worse
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.9% · Q3 1.5% · Q4 1.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.0% |
78.8%
15.2 pts better
|
79.7%
14.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.5% |
20.6%
3.1 pts better
|
23.9%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 17.9% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-03 · Fire 2023-10-03
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2021-10-13 · Fire 2021-10-13
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-04
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-07-18
E · Potential for more than minimal harm
2025-06-04
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-07-18
E · Potential for more than minimal harm
2025-06-04
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-07-25
E · Potential for more than minimal harm
2025-06-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-18
E · Potential for more than minimal harm
2025-06-04
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-18
E · Potential for more than minimal harm
2023-10-03
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-10-03
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-10-03
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 2023-11-22
E · Potential for more than minimal harm
2023-10-03
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-11-22
E · Potential for more than minimal harm
2023-10-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-22
E · Potential for more than minimal harm
2023-10-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-22
E · Potential for more than minimal harm
2023-10-03
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-11-22
E · Potential for more than minimal harm
2023-10-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-22
E · Potential for more than minimal harm
2023-10-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-22
E · Potential for more than minimal harm
2021-10-13
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Not marked corrected
E · Potential for more than minimal harm
2021-10-13
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Not marked corrected
E · Potential for more than minimal harm
2021-10-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-10-13
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 2021-11-30
E · Potential for more than minimal harm
2021-10-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-10-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-11-30
D · Potential for more than minimal harm
2021-10-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-11-30
Inspection history
Recent health citations
G · Actual harm
2026-01-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-23
D · Potential for more than minimal harm
2026-01-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-23
D · Potential for more than minimal harm
2025-08-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-06-04
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-04
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 2025-07-18
D · Potential for more than minimal harm
2025-06-04
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-04
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-18
D · Potential for more than minimal harm
2023-10-03
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 2023-11-22
D · Potential for more than minimal harm
2023-10-03
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-03
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 2023-11-22
D · Potential for more than minimal harm
2023-10-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-22
B · Minimal harm
2023-10-03
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-11-22
D · Potential for more than minimal harm
2021-10-13
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 2021-11-30
B · Minimal harm
2021-10-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-11-30
Penalties and ownership
What sits behind the stars
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
Rubin, Jeffrey
Operational/Managerial Control · Individual
Setlock, Shane
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Autumn View Health Care Facility L L C
Hamburg, NY
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Father Baker Manor
Orchard Park, NY
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Fox Run At Orchard Park
Orchard Park, NY
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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