Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 1
Feb 27, 2024
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with professional standards of practice and care plans for residents.
Findings
The facility failed to ensure that Resident #67 received wound treatment according to physician orders. Licensed practical nurse #12 substituted the ordered iodine-based treatment with an antimicrobial dressing and medicated honey without consulting the provider, contrary to facility policy and physician instructions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensed practical nurse administered wound treatment to Resident #67's foot that was not consistent with the physician ordered Betadine solution treatment. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Treatment soak volume: 50
Treatment soak duration: 5
Time for supply delivery: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #12 | Licensed Practical Nurse | Administered wound treatment inconsistent with physician orders |
| Licensed Practical Nurse Supervisor #13 | Licensed Practical Nurse Supervisor | Supervised treatment and provided information on supply ordering |
| Registered Nurse Unit Manager #6 | Registered Nurse Unit Manager | Stated treatments should be followed as per physician orders |
| Director of Nursing | Director of Nursing | Stated nursing must implement orders timely and not substitute treatments without consulting provider |
| Physician #4 | Physician | Stated nursing should not use alternative treatments without consulting medical provider |
Inspection Report
Annual Inspection
Deficiencies: 6
Feb 27, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with professional standards of practice, care plans, and regulatory requirements in the facility.
Findings
The facility was found deficient in multiple areas including failure to provide treatment and care according to physician orders, inadequate pain management, food served at unsafe and unpalatable temperatures, improper food storage and sanitation, lapses in infection prevention and control practices including PPE use, incomplete Legionella program assessments, and ineffective pest control with presence of fruit flies in the kitchen.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to provide wound treatment consistent with physician orders for Resident #67. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe, appropriate pain management for Resident #143; pain patch not applied but documented as administered. | Level of Harm - Minimal harm or potential for actual harm |
| Food and drink not palatable, flavorful, or served at safe and appetizing temperatures for meals reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Food not stored, prepared, distributed, and served in accordance with professional standards; unclean kitchen areas and expired/undated food found. | Level of Harm - Minimal harm or potential for actual harm |
| Infection prevention and control program deficiencies including improper PPE use and incomplete Legionella program assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Ineffective pest control program; presence of fruit flies in the main kitchen. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Dates of survey: 2024-02-21 to 2024-02-27
Number of residents affected: 1
Number of residents affected: 1
Number of residents affected: 2
Number of residents affected: 4
Dates of expired food items: 2023
Pest control vendor reports reviewed: 8/8/2023 to 2/13/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #12 | Licensed Practical Nurse | Administered wound treatment inconsistent with physician orders for Resident #67 |
| Licensed Practical Nurse Supervisor #13 | Licensed Practical Nurse Supervisor | Supervised wound care and discussed supply ordering for Resident #67 |
| Registered Nurse Unit Manager #6 | Registered Nurse Unit Manager | Provided expectations on treatment adherence and medication administration |
| Physician #4 | Physician | Provided medical orders and expectations for wound and pain management |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Failed to apply pain patch as ordered for Resident #143 and documented administration |
| Director of Nursing | Director of Nursing | Provided oversight expectations on treatment orders and infection control practices |
| Director of Dietary Services | Director of Dietary Services | Discussed food temperature standards and food storage deficiencies |
| Maintenance Director | Maintenance Director | Discussed Legionella program deficiencies and pest control issues |
| Activities Aide #15 | Activities Aide | Observed improper PPE removal and disposal during care of Resident #82 |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Observed improper PPE removal and handling during care of Resident #82 |
| Certified Nurse Aide #16 | Certified Nurse Aide | Observed improper PPE use and hand hygiene during care of Resident #82 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Feb 27, 2024
Visit Reason
Inspection found multiple Level 2 deficiencies in standard health and life safety code citations, all corrected by April 2024.
Findings
Inspection found multiple Level 2 deficiencies in standard health and life safety code citations, all corrected by April 2024.
Deficiencies (9)
| Description | Severity |
|---|---|
| Food procurement,store/prepare/serve-sanitary | Level 2 |
| Infection prevention & control | Level 2 |
| Maintains effective pest control program | Level 2 |
| Nutritive value/appear, palatable/prefer temp | Level 2 |
| Pain management | Level 2 |
| Quality of care | Level 2 |
| Egress doors | Level 2 |
| Sprinkler system - maintenance and testing | Level 2 |
| Subdivision of building spaces - smoke barrie | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
Nov 20, 2023
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network; not corrected at time of report.
Findings
One Level 2 deficiency related to reporting to the national health safety network; not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Plan of Correction
Deficiencies: 0
May 9, 2023
Visit Reason
This document is a statement of deficiencies and plan of correction for Elderwood at Liverpool, summarizing the findings of a survey completed on 2023-05-09.
Findings
No health deficiencies were found during the survey.
Inspection Report
Capacity: 60
Deficiencies: 1
Dec 5, 2022
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network; not corrected at time of report.
Findings
One Level 2 deficiency related to reporting to the national health safety network; not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Dec 3, 2022
Visit Reason
One Level 2 deficiency for investigating/preventing/correcting alleged violation; corrected by December 30, 2022.
Findings
One Level 2 deficiency for investigating/preventing/correcting alleged violation; corrected by December 30, 2022.
Deficiencies (1)
| Description | Severity |
|---|---|
| Investigate/prevent/correct alleged violation | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
Nov 28, 2022
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network; not corrected at time of report.
Findings
One Level 2 deficiency related to reporting to the national health safety network; not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
Sep 19, 2022
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network; not corrected at time of report.
Findings
One Level 2 deficiency related to reporting to the national health safety network; not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Nov 24, 2021
Visit Reason
One Level 2 deficiency for investigating/preventing/correcting alleged violation; corrected by December 24, 2021.
Findings
One Level 2 deficiency for investigating/preventing/correcting alleged violation; corrected by December 24, 2021.
Deficiencies (1)
| Description | Severity |
|---|---|
| Investigate/prevent/correct alleged violation | Level 2 |
Inspection Report
Annual Inspection
Deficiencies: 2
Oct 21, 2021
Visit Reason
The inspection was conducted as a federal recertification survey from 10/18/21 through 10/21/21 to assess compliance with regulatory requirements including Life Safety Code and food service standards.
Findings
The facility failed to post the Life Safety Code survey results from the previous 5/17/19 survey in a place accessible to residents and families. Additionally, the facility failed to ensure food and drink were served at palatable and safe temperatures during two meals reviewed, with multiple residents reporting cold or lukewarm food and beverages.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to post the Life Safety Code survey results from the 5/17/19 federal recertification survey in a place readily accessible to residents and families. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures for 2 of 2 meals reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Food temperatures: 55
Food temperatures: 104
Food temperatures: 105
Food temperatures: 58
Food temperatures: 110
Food temperatures: 125
Food temperatures: 61
Food temperatures: 57.6
Food temperatures: 62
Food temperatures: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| receptionist #5 | Responsible for checking and ensuring the survey results binder was kept in the drawer near the reception area. | |
| Food Service Director | Provided information about food temperature complaints, food service procedures, and staffing impacting food temperatures. | |
| Administrator | Verified the Life Safety Code survey report was missing and described posting responsibilities. |
Inspection Report
Annual Inspection
Deficiencies: 3
May 20, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for nursing home care, including activities of daily living assistance, food safety, and infection control.
Findings
The facility was found deficient in providing adequate assistance with activities of daily living for one resident, improper food handling with unpasteurized eggs served to three residents, and failure to maintain proper infection prevention practices during medication administration for three residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide facial grooming and change soiled clothing for Resident #49 as care planned. | Level of Harm - Minimal harm or potential for actual harm |
| Food service safety deficiency: unpasteurized eggs served to Residents #10, 72, and 73 that were not cooked until all parts were firm. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to perform hand hygiene between residents during medication administration for Residents #11, 60, and 67. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #4 | Interviewed regarding Resident #49's grooming and clothing care | |
| Registered Nurse (RN) Unit Manager #5 | Interviewed regarding care expectations for Resident #49 | |
| Director of Dietary Services | Interviewed regarding use of unpasteurized eggs and food safety | |
| Licensed Practical Nurse (LPN) #6 | Observed and interviewed regarding hand hygiene during medication administration | |
| Director of Nursing (DON) | Interviewed regarding hand hygiene expectations and competencies |
Inspection Report
Capacity: 60
Deficiencies: 0
Visit Reason
Two inspections resulted in no citations.
Findings
Two inspections resulted in no citations.
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