Lancaster, NY

Elderwood At Lancaster

3-star overall rating with 2-star inspections with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

1818 Como Park Blvd, Lancaster, NY

(716) 683-6165

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

96

Certified beds

Average residents

89

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Elderwood

Operator or chain grouping

Approved since

1977-01-01

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

1.01

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

0.35

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

1.77

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.13

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.36

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

2.71

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.85

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.20

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

1.06

CMS adjusted RN staffing hours

Adjusted total hours

3.27

CMS adjusted total nurse staffing hours

Case-mix index

1.31

Higher values indicate more complex resident acuity

RN turnover

68%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

72%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,853

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

10.04

Composite VBP score used to determine payment impact.

Payment multiplier

0.9809

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.54

Baseline 17.85% · Performance 20.72% · Measure score 1.54 · Achievement 1.54 · Improvement 0

Healthcare-associated infections

0.78

Baseline 5.79% · Performance 7.60% · Measure score 0.78 · Achievement 0.78 · Improvement 0

Total nurse turnover

0

Baseline 52.08% · Performance 69.07% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

1.70

Baseline 3.46 hours · Performance 3.56 hours · Measure score 1.70 · Achievement 1.70 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.21%	10.72% 0.5 pts better	No Different than the National Rate · Eligible stays 116 · Observed rate 7.76% · Lower 95% interval 6.65%
Discharge to community	52.75%	50.57% 2.2 pts better	No Different than the National Rate · Eligible stays 120 · Observed rate 50.83% · Lower 95% interval 44.36%
Medicare spending per beneficiary	0.67	1.02 0.3 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 75 · Denominator 75
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 75
Discharge self-care score	58.93%	53.69% 5.2 pts better	Numerator 33 · Denominator 56
Discharge mobility score	69.64%	50.94% 18.7 pts better	Numerator 39 · Denominator 56
Pressure ulcers or injuries, new or worsened	2.67%	2.29% 0.4 pts worse	Numerator 2 · Denominator 75 · Adjusted rate 3.33%
Healthcare-associated infections requiring hospitalization	7.6%	7.12% 0.5 pts worse	No Different than the National Rate · Eligible stays 67 · Observed rate 7.46% · Lower 95% interval 4.22%
Staff COVID-19 vaccination coverage	3.01%	8.2% 5.2 pts worse	Numerator 4 · Denominator 133
Staff flu vaccination coverage	11.8%	42% 30.2 pts worse	Numerator 21 · Denominator 178
Discharge function score	71.43%	56.45% 15 pts better	Numerator 40 · Denominator 56
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Transfer of health information to patient	71.7%	96.28% 24.6 pts worse	Numerator 38 · Denominator 53
Resident COVID-19 vaccinations up to date	35.71%	25.2% 10.5 pts better	Numerator 10 · Denominator 28

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	61.5%	91.2% 29.7 pts worse	93.4% 31.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 77.4% · Q2 73.4% · Q3 41.0% · Q4 53.8% · 4Q avg 61.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.8%	95.3% 0.5 pts better	95.5% 0.3 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8%
Percentage of long-stay residents experiencing one or more falls with major injury	6.0%	3.0% 3 pts worse	3.3% 2.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 7.8% · Q3 6.6% · Q4 6.2% · 4Q avg 6.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	4.7%	18.5% 13.8 pts better	11.4% 6.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.3% · Q3 3.4% · Q4 5.5% · 4Q avg 4.7%
Percentage of long-stay residents who lose too much weight	2.6%	6.1% 3.5 pts better	5.4% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.8% · Q4 4.1% · 4Q avg 2.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.0%	13.5% 5.5 pts worse	19.6% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 19.3% · Q3 20.7% · Q4 17.2% · 4Q avg 19.0%
Percentage of long-stay residents who received an antipsychotic medication	12.7%	14.8% 2.1 pts better	16.7% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 14.6% · Q3 10.2% · Q4 6.2% · 4Q avg 12.7% · 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	29.1%	15.1% 14 pts worse	16.3% 12.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 29.3% · Q4 38.6% · 4Q avg 29.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.1%	15.5% 2.6 pts worse	14.9% 3.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 28.8% · Q3 12.7% · Q4 15.0% · 4Q avg 18.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	0.6% 0.1 pts better	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.8%	1.4% 0.6 pts better	1.7% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.0%	20.8% 3.2 pts worse	19.8% 4.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 24.4% · Q3 21.0% · Q4 24.2% · 4Q avg 24.0%
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 11.4% · Q2 9.1% · Q3 7.4% · Q4 9.0% · 4Q avg 9.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	37.9%	76.7% 38.8 pts worse	81.7% 43.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 46.2% · Q2 40.0% · Q3 32.9% · Q4 33.0% · 4Q avg 37.9%
Percentage of short-stay residents who had an outpatient emergency department visit	4.6%	9.7% 5.1 pts better	12.0% 7.4 pts better	Short Stay · 20240701-20250630 · Adjusted 4.6% · Observed 4.5% · Expected 11.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.5%	1.2% 0.7 pts better	1.6% 1.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.7% · Q3 0.7% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	50.2%	78.8% 28.6 pts worse	79.7% 29.5 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 50.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.1%	20.6% 3.5 pts worse	23.9% 0.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 27.3% · Expected 27.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-22 · Fire 2024-11-22

12 health deficiencies

Top issue: Resident Rights (4 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2022-12-06 · Fire 2022-12-06

2 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2019-12-20 · Fire 2019-12-20

2 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

3 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-11-22

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-11-22

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-01-10

E · Potential for more than minimal harm 2019-12-20

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2020-02-06

C · Minimal harm 2019-12-20

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2020-02-06

C · Minimal harm 2019-12-20

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2020-02-06

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-23

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 2026-02-06

D · Potential for more than minimal harm 2025-12-23

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 2026-02-06

F · Potential for more than minimal harm 2024-11-22

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2025-01-10

F · Potential for more than minimal harm 2024-11-22

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2025-01-10

F · Potential for more than minimal harm 2024-11-22

F840 · Administration Deficiencies

Health

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Corrected 2025-01-15

D · Potential for more than minimal harm 2024-11-22

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 2025-01-10

D · Potential for more than minimal harm 2024-11-22

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-11-22

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-11-22

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-11-22

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 2025-01-10

D · Potential for more than minimal harm 2024-11-22

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 2025-01-10

D · Potential for more than minimal harm 2024-11-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-10-18

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-12-02

D · Potential for more than minimal harm 2022-12-06

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-02-02

D · Potential for more than minimal harm 2019-12-20

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2020-02-14

D · Potential for more than minimal harm 2019-12-20

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2020-02-14

Penalties and ownership