Inspection Reports for
Elderwood at North Creek
112 Ski Bowl Road, North Creek, NY, 12853
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
169% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 16
Date: Sep 20, 2024
Visit Reason
Inspection identified multiple standard health and life safety code deficiencies, all corrected by November 2024.
Findings
Inspection identified multiple standard health and life safety code deficiencies, all corrected by November 2024.
Deficiencies (16)
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 20, 2024
Visit Reason
The inspection was a recertification survey to evaluate the facility's housekeeping and maintenance services and overall compliance with safety and environmental standards.
Findings
The facility failed to provide effective housekeeping and maintenance services on two resident units (A and B wings) and the building exterior. Multiple areas including floors, walls, ceilings, sinks, and exterior stucco were found to be soiled, damaged, or in disrepair.
Deficiencies (4)
Floors, walls, ceilings, sinks, and building exterior were not clean or maintained, including chipped door jams, cracked walls, dirty air vents, missing ceiling tiles, and sticky corridor floors on the A-Wing unit.
Exterior building stucco was falling off, missing, peeling, or chipped in multiple locations including garage, employee dining room, and Rotunda, with dirt drip marks and peeling paint under resident rooms on the A-Wing.
Resident room walls on the B-Wing were soiled with scrape marks or grime, with peeling or gouged walls behind beds in several rooms, soiled heater registers, and scraped bathroom door frames.
Walls were chipped around closets in rooms 205 and 215; ceiling tiles missing in rooms 201 and 207; corridor walls soiled, peeling, or chipped; floors soiled with ground-in dirt; and kitchenette sink was not working.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator #1 | Stated the facility would clean, repair, and repaint walls and floors on A-Wing and B-Wing and the building exterior, develop new cleaning and painting schedules, and repair the kitchenette sink. |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Sep 20, 2024
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory standards for nursing home operations, including housekeeping, respiratory care, medication management, food service, waste disposal, and infection control.
Findings
The facility was found deficient in multiple areas including ineffective housekeeping and maintenance, inadequate respiratory care practices, improper medication labeling and storage, food service safety violations, improper garbage disposal, and failure to follow infection prevention and control protocols, particularly related to COVID-19 precautions.
Deficiencies (6)
F 0584: The facility did not provide effective housekeeping and maintenance services on two resident units and the building exterior. Floors, walls, ceilings, sinks, and building exterior were soiled or in disrepair.
F 0695: The facility failed to ensure residents received necessary respiratory care. Oxygen tubing for three residents was not labeled or dated when changed, and one resident's portable oxygen tank was empty.
F 0761: Drugs and biologicals were not labeled or stored according to professional standards. Opened insulin vials and pens lacked proper open and expiration dates on labels.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards. Kitchen equipment and floors were soiled, and equipment and walls were in disrepair.
F 0814: The facility did not properly dispose of garbage and refuse. Dumpster lids and doors were left open and refuse was found on the ground.
F 0880: The facility failed to implement infection prevention and control practices. Staff did not use appropriate personal protective equipment when entering rooms of COVID-19 positive residents and those on Contact/Droplet Precautions.
Report Facts
Residents reviewed for oxygen administration: 3
Medication carts reviewed: 2
Dumpster count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #3 | Certified Nurse Aide | Observed not wearing appropriate PPE entering a resident's room on Transmission/Contact/Droplet Precautions |
| Certified Nurse Aide #4 | Certified Nurse Aide | Observed not using hand sanitizer after glove removal and entering locked utility room |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Stated oxygen tubing should be changed weekly and labeled; acknowledged issue with oxygen administration |
| Director of Nursing #1 | Director of Nursing | Provided statements on oxygen administration policies and medication labeling practices |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Discussed oxygen tubing labeling standardization and infection control policies |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Discussed medication labeling and expiration date requirements |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Discussed medication cart checks and removal of discontinued medications |
| Certified Nurse Aide #1 | Certified Nurse Aide | Observed entering COVID positive resident room without appropriate PPE |
| Certified Nurse Aide #2 | Certified Nurse Aide | Observed delivering meal trays without PPE in COVID positive resident rooms |
| Licensed Practical Nurse/Unit Manager #3 | Licensed Practical Nurse/Unit Manager | Stated staff should wear PPE when providing care and wear N95 masks for COVID positive residents |
| Administrator #1 | Administrator | Stated plans to repair and clean facility areas and re-educate staff on dumpster closure |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 5
Date: Sep 19, 2024
Visit Reason
Inspection found deficiencies in emergency preparedness plans and collaboration processes, all corrected by November 2024.
Findings
Inspection found deficiencies in emergency preparedness plans and collaboration processes, all corrected by November 2024.
Deficiencies (5)
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Apr 8, 2022
Visit Reason
Inspection revealed deficiencies in respiratory care and electrical system maintenance, all corrected by June 2022.
Findings
Inspection revealed deficiencies in respiratory care and electrical system maintenance, all corrected by June 2022.
Deficiencies (4)
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 8, 2022
Visit Reason
The inspection was a recertification survey conducted from April 4, 2022 through April 8, 2022 to assess compliance with professional standards of care and regulatory requirements.
Findings
The facility failed to provide safe and appropriate respiratory care for Resident #47 by not ensuring the resident received 4 liters of continuous oxygen as ordered and by not consistently monitoring and documenting oxygen saturation every shift as required by the physician order.
Deficiencies (1)
F 0695: The facility did not ensure Resident #47 received 4 liters of continuous oxygen via nasal cannula as ordered. Oxygen saturation was not consistently monitored and documented every shift for hypoxemic respiratory failure as required by the physician order.
Report Facts
Observation oxygen flow rates: 3
Oxygen saturation percentages: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physical Therapist #1 | Physical Therapist | Reported Resident #47 had oxygen tubing misplaced and noted oxygen saturation changes during observation. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Reviewed physician order and explained oxygen administration and documentation requirements. |
| Director of Nursing | Director of Nursing | Reviewed oxygen order and confirmed resident was to be on 4 liters continuous oxygen. |
| Registered Nurse #1 | Registered Nurse | Discussed care planning and nursing responsibilities related to oxygen therapy. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed oxygen concentrator setting and discussed documentation practices. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Nov 1, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with state and federal regulations for nursing home operation.
Findings
The facility was found deficient in timely physician notification of significant resident condition changes, failure to provide written bed hold and return policy notices upon hospital transfer, incomplete PASARR screening documentation, inadequate ongoing activity programs tailored to resident preferences, and lack of a defined time frame for physician documentation in monthly medication regimen reviews.
Deficiencies (5)
10NYCRR415.3(e)(2)(ii)(b) The facility did not ensure timely physician notification for a resident's significant change in condition, specifically low blood pressure and oxygen saturation on 9/28/19.
10NYCRR415.3(h)(4(i)(a)) The facility failed to provide written notice of bed hold and return policy at the time of hospital transfer for three residents.
10NYCRR415.11(e) The facility did not complete the PASARR SCREEN form properly, leaving a key question about serious mental illness unanswered for one resident.
10NYCRR 415.5(f)(1) The facility did not ensure an ongoing activity program that supported residents' choices and interests, failing to provide adequate activities for two residents.
10NYCRR415.18 (c)(2) The facility did not develop a policy with time frames for physician documentation and action following irregularities identified in monthly medication regimen reviews.
Report Facts
Residents reviewed for hospitalization bed hold notices: 3
Residents reviewed for PASARR screening: 19
Residents reviewed for activities: 2
Activity attendance days for Resident #13: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager #1 | RN Unit Manager | Named in finding regarding failure to notify physician of resident's low blood pressure. |
| Director of Nursing | DON | Stated that physician notification should have occurred and bed hold notifications were inconsistent. |
| Medical Director | Medical Director | Stated physician should have been notified of resident's condition change. |
| Administrative Assistant | Nursing Administrative Assistant | Reported bed hold notifications were not provided at time of transfer. |
| Administrator | Facility Administrator | Acknowledged sporadic bed hold notices and lack of time frame in medication review policy. |
| Regional Director of Operations | Regional Director of Operations | Unaware of missing time frame in medication regimen review policy. |
| Acting Activity Director | Activity Director | Reported limited activities for younger residents and staffing constraints. |
| Activities Staff member #2 | Activities Staff | Reported resident attendance and participation in activities. |
| Activities Staff member #3 | Activities Staff | Reported resident attendance and participation in activities. |
| Regional Memory Care Consultant | Memory Care Consultant | Stated all residents should be invited to activities and staff should assist participation. |
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