Niagara Falls, NY

Elderwood At Wheatfield

2-star overall rating with 2-star inspections with 12 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle

2600 Niagara Falls Boulevard, Niagara Falls, NY

(716) 215-8000

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

123

Certified beds

Average residents

116

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Elderwood

Operator or chain grouping

Approved since

1995-10-18

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

0.71

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

0.76

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

1.65

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

1.48

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

2.61

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.42

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.16

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.72

CMS adjusted RN staffing hours

Adjusted total hours

3.14

CMS adjusted total nurse staffing hours

Case-mix index

1.36

Higher values indicate more complex resident acuity

RN turnover

54%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

60%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,890

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

Performance score

22.13

Composite VBP score used to determine payment impact.

Payment multiplier

0.9828

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 18.65% · Performance 23.68% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

6.68

Baseline 6.67% · Performance 5.84% · Measure score 6.68 · Achievement 6.68 · Improvement 4.45

Total nurse turnover

1.51

Baseline 54.39% · Performance 57.52% · Measure score 1.51 · Achievement 1.51 · Improvement 0

Adjusted total nurse staffing

0.67

Baseline 3.71 hours · Performance 3.27 hours · Measure score 0.67 · Achievement 0.67 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.51%	10.72% 0.8 pts worse	No Different than the National Rate · Eligible stays 141 · Observed rate 10.64% · Lower 95% interval 8.32%
Discharge to community	53.32%	50.57% 2.8 pts better	No Different than the National Rate · Eligible stays 155 · Observed rate 50.32% · Lower 95% interval 46.72%
Medicare spending per beneficiary	0.95	1.02 0.1 pts better
Drug regimen review with follow-up	97.73%	95.27% 2.5 pts better	Numerator 86 · Denominator 88
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 88
Discharge self-care score	60.29%	53.69% 6.6 pts better	Numerator 41 · Denominator 68
Discharge mobility score	41.18%	50.94% 9.8 pts worse	Numerator 28 · Denominator 68
Pressure ulcers or injuries, new or worsened	10.23%	2.29% 7.9 pts worse	Numerator 9 · Denominator 88 · Adjusted rate 12.5%
Healthcare-associated infections requiring hospitalization	5.84%	7.12% 1.3 pts better	No Different than the National Rate · Eligible stays 115 · Observed rate 3.48% · Lower 95% interval 2.96%
Staff COVID-19 vaccination coverage	3.86%	8.2% 4.3 pts worse	Numerator 8 · Denominator 207
Staff flu vaccination coverage	30.21%	42% 11.8 pts worse	Numerator 87 · Denominator 288
Discharge function score	58.82%	56.45% 2.4 pts better	Numerator 40 · Denominator 68
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to patient	96.23%	96.28% About the same	Numerator 51 · Denominator 53
Resident COVID-19 vaccinations up to date	33.33%	25.2% 8.1 pts better	Numerator 11 · Denominator 33

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.5	1.7 0.2 pts better	1.9 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.0 · Expected 1.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.3	1.3 About the same	1.8 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	85.1%	91.2% 6.1 pts worse	93.4% 8.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 90.8% · Q2 87.1% · Q3 82.8% · Q4 80.0% · 4Q avg 85.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	90.4%	95.3% 4.9 pts worse	95.5% 5.1 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 90.4%
Percentage of long-stay residents experiencing one or more falls with major injury	9.2%	3.0% 6.2 pts worse	3.3% 5.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 9.4% · Q3 5.7% · Q4 11.1% · 4Q avg 9.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.6%	18.5% 12.9 pts better	11.4% 5.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.3% · Q3 4.4% · Q4 10.0% · 4Q avg 5.6%
Percentage of long-stay residents who lose too much weight	7.2%	6.1% 1.1 pts worse	5.4% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 10.1% · Q3 9.0% · Q4 6.2% · 4Q avg 7.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	7.6%	13.5% 5.9 pts better	19.6% 12 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 7.3% · Q3 6.1% · Q4 7.1% · 4Q avg 7.6%
Percentage of long-stay residents who received an antipsychotic medication	14.9%	14.8% 0.1 pts worse	16.7% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 14.9% · Q3 16.4% · Q4 12.1% · 4Q avg 14.9% · 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	24.9%	15.1% 9.8 pts worse	16.3% 8.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 19.5% · Q3 26.8% · Q4 29.7% · 4Q avg 24.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	23.2%	15.5% 7.7 pts worse	14.9% 8.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 20.7% · Q3 25.6% · Q4 23.2% · 4Q avg 23.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.6% 0.2 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.3%	1.4% 1.1 pts better	1.7% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	34.9%	20.8% 14.1 pts worse	19.8% 15.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 34.0% · Q3 39.3% · Q4 41.6% · 4Q avg 34.9%
Percentage of long-stay residents with pressure ulcers	13.9%	6.9% 7 pts worse	5.1% 8.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 9.7% · Q3 12.9% · Q4 15.5% · 4Q avg 13.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	72.8%	76.7% 3.9 pts worse	81.7% 8.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 77.7% · Q2 80.7% · Q3 67.2% · Q4 67.3% · 4Q avg 72.8%
Percentage of short-stay residents who had an outpatient emergency department visit	13.0%	9.7% 3.3 pts worse	12.0% 1 pts worse	Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 12.3% · Expected 10.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.1%	1.2% 0.1 pts better	1.6% 0.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.8% · Q3 0.7% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	82.2%	78.8% 3.4 pts better	79.7% 2.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 82.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.8%	20.6% 0.2 pts worse	23.9% 3.1 pts better	Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 20.0% · Expected 22.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-08-14 · Fire 2024-08-14

12 health deficiencies

Top issue: Resident Rights (3 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2022-11-09 · Fire 2022-11-09

0 health deficiencies

No concentrated health issue counts in this cycle.

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-12-06 · Fire 2019-12-06

1 health deficiencies

Top issue: Infection Control (1 deficiency)

4 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-08-14

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2024-10-11

E · Potential for more than minimal harm 2024-08-14

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 2024-10-11

E · Potential for more than minimal harm 2024-08-14

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-10-11

E · Potential for more than minimal harm 2024-08-14

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-11

E · Potential for more than minimal harm 2024-08-14

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-10-11

E · Potential for more than minimal harm 2024-08-14

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-10-11

E · Potential for more than minimal harm 2024-08-14

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-10-11

E · Potential for more than minimal harm 2024-08-14

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-10-11

D · Potential for more than minimal harm 2024-08-14

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-10-11

D · Potential for more than minimal harm 2024-08-14

K374 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-10-11

E · Potential for more than minimal harm 2022-11-09

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 2023-01-06

E · Potential for more than minimal harm 2022-11-09

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-01-06

E · Potential for more than minimal harm 2022-11-09

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-01-06

D · Potential for more than minimal harm 2022-11-09

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2023-01-06

D · Potential for more than minimal harm 2022-11-09

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2023-01-06

D · Potential for more than minimal harm 2022-11-09

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-01-06

E · Potential for more than minimal harm 2019-12-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-01-28

C · Minimal harm 2019-12-06

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2020-01-28

C · Minimal harm 2019-12-06

E20 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures including evacuation.

Corrected 2020-01-28

C · Minimal harm 2019-12-06

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2020-01-28

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-08-14

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 2024-10-11

E · Potential for more than minimal harm 2024-08-14

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2024-10-11

D · Potential for more than minimal harm 2024-08-14

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 2024-10-11

D · Potential for more than minimal harm 2024-08-14

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 2024-10-11

D · Potential for more than minimal harm 2024-08-14

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 2024-10-11

D · Potential for more than minimal harm 2024-08-14

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 2024-10-11

D · Potential for more than minimal harm 2024-08-14

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-10-11

D · Potential for more than minimal harm 2024-08-14

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 2024-10-11

D · Potential for more than minimal harm 2024-08-14

F810 · Nutrition and Dietary Deficiencies

Health

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Corrected 2024-10-11

D · Potential for more than minimal harm 2024-08-14

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-11

C · Minimal harm 2024-08-14

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-10-11

B · Minimal harm 2024-08-14

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-10-11

D · Potential for more than minimal harm 2019-12-06