Elderwood at Hamburg

In the surveyor’s words

From the most serious findings on record at Elderwood at Hamburg, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 25, 2026

  Based on interview and record review conducted during survey, the facility failed to ensure residents had the right to be free from sexual abuse for one (Resident #1) of three residents reviewed for abuse. Specifically, on 07/05/2025 Resident #2 was observed engaged in inappropriate physical contact with Resident #1. Resident #2 had wandered into Resident #1's room and was found by staff unclothed below the waist, positioned in a side lying position behind Resident #1. Resident #1's incontinence brief was displaced exposing their right buttock. Resident #1 lacked cognitive capacity to provide informed consent and exhibited emotional distress and expressed fearfulness. […]

• Actual harm, isolatedF742Aug 25, 2026

  Based on observations, interviews, and record review conducted during survey, the facility failed to ensure that each resident received necessary behavioral health care and services to attain the highest practicable mental and psychosocial well-being for one (Resident #5) of three residents reviewed for behavioral health. Specifically, upon readmission, the resident had a history of suicidal ideations and a self-harm attempt during a prior hospital stay and the facility failed to develop an individualized behavioral health care plan incorporating specific self-harm interventions. On 08/01/2026, Resident #5 verbalized self-harm statements and immediate protective interventions were not implemented which resulted in the resident causing a self-inflicted superficial cut to their left wrist. […]

• Actual harm, isolatedF689Jan 22, 2026

  Based on interview and record review conducted during the survey, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for two (2) (Resident's #1 and #2) of ten (10) residents reviewed for accidents. Specifically, facility staff failed to implement safety measures during resident repositioning. Residents were not provided with the assistance of two (2) staff members during bed mobility as planned and the bed locking systems were unlocked. […]

• No harm, potential for more than minimal, isolatedF584Aug 25, 2026

  Based on observations, interviews, and record review conducted during survey, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (Unit 2) of three resident units. Specifically, fecal matter (stool) and contaminated washcloths were observed on the floor within the shared resident shower room.The findings include:The facility policy and procedure titled Cleaning Guideline: Maintaining a Safe, Clean, Comfortable and Home-Like Environment, reviewed 06/03/2026, documented the facility would ensure that all residents were provided with a safe, clean, comfortable, home-like environments in accordance with regulations while promoting dignity. […]

• No harm, potential for more than minimal, isolatedF689Aug 25, 2026

  Based on observations, interviews, and record review conducted during survey, the facility failed to ensure that a resident received adequate supervision to prevent accidents/hazards for one (Resident #4) of three residents reviewed for accidents. Specifically, Resident #4 who was severely cognitively impaired exited the facility through a second floor pass coded stairwell door, without having to enter a passcode and was found outside the facility without injury.The findings include:The facility policy and procedure titled Elopement- Wandering- Missing Resident revised 10/08/2018, documented that all residents are assessed upon admission, annually and as needed to determine risk level for unsafe wandering/elopement. […]