Elderwood at Waverly

In the surveyor’s words

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

• Immediate jeopardy, patternF600Mar 11, 2026

  Based on record reviews and interviews during the facility failed to protect residents from sexual abuse for six (6) of six (6) residents (Residents #3, #4, #5, #6, #7, and #8). Specifically, Resident #2 was found in separate sexually inappropriate situations with six (6) residents, all of whom had impaired cognitive function with the exception of Resident #5. The facility's failure to protect residents from sexual abuse placed all 176 residents in the facility at risk of abuse. This resulted in actual harm for Residents #3, #4, #5, #6, #7, and #8 that was Immediate Jeopardy and Substantial Quality of Care for residents' health and safety. […]

• Immediate jeopardy, isolatedF578Jan 30, 2025

  Based on record review and interviews during the abbreviated survey (NY00369096), the facility failed to establish mechanisms for documenting and communicating the resident's choice regarding Advance Directives to the staff responsible for the resident's care for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 updated their Medical Orders for Life-Sustaining Treatment to reflect a change in their wishes from cardiopulmonary resuscitation (attempt to restart the heart) to do not resuscitate (allow natural death). The paper medical record (Medical Order for Life Sustaining Treatment form) and electronic medical record code status orders did not match to reflect the resident's Advance Directives wishes to allow natural death (do not resuscitate). […]

• No harm, potential for more than minimal, widespreadF909Mar 28, 2025

  Based on observations, record review, and interviews during the recertification survey conducted 3/24/2025-3/28/2025, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 7 of 7 resident beds (beds for Resident #15, #29, #31, #38, #91, #99, and #106) reviewed. Specifically, Resident #15's mattress was not securely placed within the bedframe brackets; Resident #29's mattress did not fit within the bedframe mattress brackets resulting in a gap between the mattress and the assist rail; Resident #99's mattress was not securely placed in the bedframe brackets resulting in an entrapment zone that exceeded the United States Food and Drug Administration's recommended… […]

• No harm, potential for more than minimal, patternF689Dec 29, 2023

  Based on record review and interview conducted during the abbreviated survey (NY00327113 and NY00327592), the facility did not ensure adequate supervision was provided to prevent accidents for 8 of 14 residents (Residents #3, #5, #6, #7, #8, #9, #10, and #11) reviewed. Specifically, Residents #7, #8, and #9 had histories of behaviors towards other residents and adequate supervision was not implemented to prevent further resident to resident incidents towards Residents #3, #5, #6, #8, #10, and #11. Findings include: The 1/8/2020 Enhanced Supervision Policy documented enhanced supervision was an integral part of a therapeutic plan and ensured the safe sensitive monitoring of a residents' physical and psychosocial well-being. […]

• No harm, potential for more than minimal, patternF584Apr 27, 2023

  Based on observation, record review, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 4 of 4 occupied resident floors (First, Third, and Fourth floors) reviewed. Specifically, - the fourth floor had stained ceiling tiles and the elevator alcove had a loose handrail. - the third floor had a damaged bathroom sink, the soiled utility room did not have a paper towel dispenser, and the dining room window was cracked. […]