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

Certified beds

Average residents

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

Staffing

Hours and turnover

RN hours / resident day

1.01

Registered nurse staffing

LPN hours / resident day

0.35

Licensed practical nurse staffing

Aide hours / resident day

1.77

Nurse aide staffing

Weekend hours

2.71

Weekend nurse staffing

RN turnover

68%

Annual RN turnover

Total nurse turnover

72%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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