4 Reports · 1 Summary
Inspection Summary
9 inspections covered, June 2022 – May 2026.
Inspection Reports Summary
Visit Reason
State-compiled facility profile showing 9 inspections from June 2022 to May 2026 with citation and complaint history.
Complaint Details
The state logged 104 complaints about this facility; 14 led to on-site inspections. Two citations resulted from those complaints.
Findings
Across 9 inspections, 7 resulted in citations totaling 46, including 31 standard health and 15 life safety code citations. The facility had 104 complaints with 14 on-site inspections and no formal enforcement actions.
Citations (27)
Baseline Care Plan: Standard Health Citation for quality of care related to baseline care planning deficiencies.
Dispose Garbage And Refuse Properly: Standard Health Citation for quality of care regarding improper garbage disposal.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation for quality of care related to sanitary food handling.
Infection Control: Standard Health Citation for quality of care related to infection control practices.
Infection Prevention & Control: Standard Health Citation for quality of care regarding infection prevention and control.
Label/store Drugs And Biologicals: Standard Health Citation for quality of care related to drug labeling and storage.
Medicaid/medicare Coverage/liability Notice: Standard Health Citation for quality of care concerning coverage and liability notices.
Resident/family Group And Response: Standard Health Citation for quality of care regarding resident and family group responses.
Safe/clean/comfortable/homelike Environment: Standard Health Citation for quality of care related to environment conditions.
Treatment/svcs To Prevent/heal Pressure Ulcer: Standard Health Citation for quality of care related to pressure ulcer treatment.
Electrical Systems - Essential Electric Syste: Life Safety Code Citation for NFPA requirements on electrical systems.
Elevators: Life Safety Code Citation for NFPA requirements on elevator safety.
Exit Signage: Life Safety Code Citation for NFPA requirements on exit signage.
Fire Alarm System - Testing And Maintenance: Life Safety Code Citation for NFPA requirements on fire alarm maintenance.
Hazardous Areas - Enclosure: Life Safety Code Citation for NFPA requirements on hazardous area enclosures.
Means Of Egress - General: Life Safety Code Citation for NFPA requirements on means of egress.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation for quality of care related to sanitary food handling.
Infection Prevention & Control: Standard Health Citation for quality of care regarding infection prevention and control.
Maintains Effective Pest Control Program: Standard Health Citation for quality of care related to pest control.
Nutritive Value/appear, Palatable/prefer Temp: Standard Health Citation for quality of care regarding food nutritive value and temperature.
Pain Management: Standard Health Citation for quality of care related to pain management.
Quality Of Care: Standard Health Citation for quality of care deficiencies.
Egress Doors: Life Safety Code Citation for NFPA requirements on egress doors.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation for NFPA requirements on sprinkler system maintenance.
Subdivision Of Building Spaces - Smoke Barrie: Life Safety Code Citation for NFPA requirements on smoke barriers.
Reporting - National Health Safety Network: Standard Health Citation for quality of care related to reporting requirements.
Investigate/prevent/correct Alleged Violation: Standard Health Citation for quality of care regarding investigation and correction of alleged violations.
Report Facts
Inspections on page: 9
Total violations/deficiencies cited: 46
Inspections with violations: 7
Inspections without violations: 2
Total complaints: 104
On-site complaint inspections: 14
Citations from complaints: 2
Enforcement actions: 0
Individual Reports
One document per inspection visit.
Inspection Report — Feb 27, 2024
Annual Inspection
Date: 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.
Citations (6)
Failure to provide wound treatment consistent with physician orders for Resident #67.
Failure to provide safe, appropriate pain management for Resident #143; pain patch not applied but documented as administered.
Food and drink not palatable, flavorful, or served at safe and appetizing temperatures for meals reviewed.
Food not stored, prepared, distributed, and served in accordance with professional standards; unclean kitchen areas and expired/undated food found.
Infection prevention and control program deficiencies including improper PPE use and incomplete Legionella program assessments.
Ineffective pest control program; presence of fruit flies in the main kitchen.
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 — May 9, 2023
Plan of Correction
Date: 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 — Oct 21, 2021
Annual Inspection
Date: 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.
Citations (2)
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.
Failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures for 2 of 2 meals reviewed.
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 — May 20, 2019
Annual Inspection
Date: 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.
Citations (3)
Failure to provide facial grooming and change soiled clothing for Resident #49 as care planned.
Food service safety deficiency: unpasteurized eggs served to Residents #10, 72, and 73 that were not cooked until all parts were firm.
Failure to perform hand hygiene between residents during medication administration for Residents #11, 60, and 67.
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 |
5 CMS Surveys
CMS Survey — Feb 27, 2024
Feb 27, 2024
CMS Survey — May 20, 2019
May 20, 2019
CMS Survey — Oct 21, 2021
Oct 21, 2021
CMS Survey — Feb 27, 2024
Feb 27, 2024
CMS Survey — May 9, 2023
May 9, 2023
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