Cycle 1
Health 2025-05-02 · Fire 2025-05-02
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Lockport, NY
Elderwood At Lockport
4-star overall rating with 4-star inspections with $94,185 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
104 Old Niagara Road, Lockport, NY
(716) 434-6324
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
126
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Elderwood
Operator or chain grouping
Approved since
1976-08-01
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
0.92
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.82
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
3.49
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,551
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.44
Baseline 17.57% · Performance 20.77% · Measure score 1.44 · Achievement 1.44 · Improvement 0
Healthcare-associated infections
0.87
Baseline 6.30% · Performance 7.58% · Measure score 0.87 · Achievement 0.87 · Improvement 0
Total nurse turnover
4.38
Baseline 51.18% · Performance 45.76% · Measure score 4.38 · Achievement 4.38 · Improvement 1.56
Adjusted total nurse staffing
1.30
Baseline 3.53 hours · Performance 3.45 hours · Measure score 1.30 · Achievement 1.30 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.53% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 134 · Observed rate 16.42% · Lower 95% interval 8.48% |
| Discharge to community | 54.35% |
50.57%
3.8 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 50.4% · Lower 95% interval 46.3% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.45% |
95.27%
0.2 pts better
|
Numerator 105 · Denominator 110 |
| Falls with major injury | 0.91% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 110 |
| Discharge self-care score | 43.48% |
53.69%
10.2 pts worse
|
Numerator 40 · Denominator 92 |
| Discharge mobility score | 42.39% |
50.94%
8.5 pts worse
|
Numerator 39 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 5.45% |
2.29%
3.2 pts worse
|
Numerator 6 · Denominator 110 · Adjusted rate 4.96% |
| Healthcare-associated infections requiring hospitalization | 7.57% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 8.08% · Lower 95% interval 4.39% |
| Staff COVID-19 vaccination coverage | 9.52% |
8.2%
1.3 pts better
|
Numerator 16 · Denominator 168 |
| Staff flu vaccination coverage | 46.89% |
42%
4.9 pts better
|
Numerator 113 · Denominator 241 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 46 · Denominator 92 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 56 · Denominator 56 |
| Resident COVID-19 vaccinations up to date | 35.19% |
25.2%
10 pts better
|
Numerator 19 · Denominator 54 |
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 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
91.2%
7.2 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.8% · Q3 96.8% · Q4 99.0% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.6% |
95.3%
5.7 pts worse
|
95.5%
5.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
3.0%
1.6 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.4% · Q3 6.5% · Q4 4.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
18.5%
17.6 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 11.6% |
6.1%
5.5 pts worse
|
5.4%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 13.6% · Q3 11.8% · Q4 9.9% · 4Q avg 11.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
13.5%
1.9 pts worse
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 16.9% · Q3 14.0% · Q4 15.5% · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.4% |
14.8%
1.6 pts worse
|
16.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 21.1% · Q3 16.2% · Q4 16.5% · 4Q avg 16.4% · 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 | 31.9% |
15.1%
16.8 pts worse
|
16.3%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 46.5% · Q3 42.4% · Q4 11.0% · 4Q avg 31.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.2% |
15.5%
9.7 pts worse
|
14.9%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 31.4% · Q3 29.1% · Q4 19.4% · 4Q avg 25.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.6%
1.2 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.2% · Q3 1.2% · Q4 1.6% · 4Q avg 1.8% · 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 1.2% · Q2 1.1% · Q3 1.1% · 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 | 36.3% |
20.8%
15.5 pts worse
|
19.8%
16.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 43.2% · Q3 30.0% · Q4 39.1% · 4Q avg 36.3% |
| Percentage of long-stay residents with pressure ulcers | 16.6% |
6.9%
9.7 pts worse
|
5.1%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 14.7% · Q3 20.4% · Q4 18.6% · 4Q avg 16.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.8% |
76.7%
15.1 pts better
|
81.7%
10.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 89.9% · Q3 93.0% · Q4 92.5% · 4Q avg 91.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.7% |
9.7%
5 pts better
|
12.0%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.7% · Observed 4.7% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.2%
0.2 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 2.2% · Q4 1.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.6% |
78.8%
8.8 pts better
|
79.7%
7.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
20.6%
2.1 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 17.6% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-06 · Fire 2023-06-06
5 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-07-30 · Fire 2021-07-30
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-30
E · Potential for more than minimal harm
2023-06-06
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-06-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-06-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-06-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-06-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-06-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-06-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-06-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-06-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-31
E · Potential for more than minimal harm
2021-07-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-09-28
D · Potential for more than minimal harm
2021-07-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-09-28
D · Potential for more than minimal harm
2021-07-30
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2021-09-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-02
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 2025-07-01
D · Potential for more than minimal harm
2025-05-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-01
E · Potential for more than minimal harm
2023-06-06
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 2023-07-31
D · Potential for more than minimal harm
2023-06-06
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 2023-07-31
D · Potential for more than minimal harm
2023-06-06
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 2023-07-31
D · Potential for more than minimal harm
2023-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-14
B · Minimal harm
2023-06-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-07-31
D · Potential for more than minimal harm
2021-07-30
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2021-09-28
D · Potential for more than minimal harm
2021-07-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-28
Penalties and ownership
What sits behind the stars
$94,185
2025-05-02
Fine
Fine · fine $94,185
Fine
Ownership
104 Old Niagara Road Operating Holdco, LLC
5% Or Greater Direct Ownership Interest · Organization
Cole, Warren
5% Or Greater Indirect Ownership Interest · Individual
Rubin, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Cole, Warren
Operational/Managerial Control · Individual
Cole, Warren
Corporate Officer · Individual
Quillard, Philip
Operational/Managerial Control · Individual
Quillard, Philip
Corporate Officer · Individual
Rubin, Jeffrey
Operational/Managerial Control · Individual
Rubin, Jeffrey
Corporate Officer · Individual
Setlock, Shane
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Lockport Rehab & Health Care Center
Lockport, NY
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Absolut Ctr For Nursing & Rehab Gasport L L C
Gasport, NY
2-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Newfane Rehab & Health Care Center
Newfane, NY
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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