Inspection Reports for
Elderwood at Ticonderoga
101 Adirondack Drive, Ticonderoga, NY, 12883
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
88% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Aug 20, 2025
Visit Reason
The abbreviated survey was conducted to investigate compliance with care standards related to a resident's significant change in condition and catheter care.
Findings
The facility failed to immediately notify the physician when a resident pulled out their urinary catheter and did not provide appropriate catheter care as required by professional standards. Documentation and physician orders for catheter care were lacking, and the resident was eventually transferred to the hospital following a rapid decline.
Deficiencies (2)
F 0580: The facility did not ensure immediate physician notification when Resident #1 pulled out their urinary catheter, violating the policy for change in resident condition.
F 0690: The facility failed to provide appropriate care for a resident with an indwelling catheter, lacking documented catheter care and physician orders for catheter management.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #4 | Nurse responsible for Resident #1 at time of catheter removal incident | |
| Licensed Practical Nurse #1 | Nurse caring for Resident #1 on day of catheter removal, did not notify physician | |
| Registered Nurse #1 | Assumed care of Resident #1 after catheter removal incident | |
| Director of Nursing #1 | Provided statements regarding lack of physician notification and catheter care orders | |
| Administrator #1 | Provided statements regarding resident's hospital transfer |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Aug 20, 2025
Visit Reason
Two Level 2 deficiencies related to bowel/bladder incontinence and notification of changes; both corrected by September 8, 2025.
Findings
Two Level 2 deficiencies related to bowel/bladder incontinence and notification of changes; both corrected by September 8, 2025.
Deficiencies (2)
Bowel/bladder incontinence, catheter, uti
Notify of changes (injury/decline/room, etc.)
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 15, 2024
Visit Reason
The survey was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements.
Findings
The facility failed to conduct a thorough and accurate investigation after an injury of unknown origin was observed on Resident #48. The injury was noted as bruising to the resident's right eye, but no nursing assessment or investigation was documented at the time.
Deficiencies (1)
F 0610: The facility did not ensure a thorough investigation was conducted after bruising of unknown origin was observed on Resident #48's right eye. No nursing assessment or documentation of the injury was completed at the time of observation.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #3 | Registered Nurse | Completed Incident Report and provided statements regarding the injury to Resident #48 |
| Nursing Home Administrator #1 | Nursing Home Administrator | Interviewed regarding lack of investigation into Resident #48's injury |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding policy and procedures for investigating injuries of unknown origin |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jul 15, 2024
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints, incomplete care plans, inadequate activities programming, insufficient nutritional and hydration care, medication administration errors, improper medication storage and labeling, and food quality and preparation issues.
Deficiencies (8)
F0604: The facility used a chair alarm as a restraint without proper assessment or documentation, violating residents' rights to be free from physical restraints.
F0656: The facility failed to develop and implement a comprehensive care plan for the use of a chair alarm for Resident #47.
F0679: The facility did not provide ongoing activities that met the interests and needs of residents #10 and #24, with documented lack of engagement and insufficient staffing.
F0692: The facility failed to provide adequate nutritional and hydration care for residents #3, #23, #24, and #63, including failure to monitor weight loss, provide correct diet consistency, and offer fluids between meals.
F0755: The facility did not ensure accurate and timely documentation of controlled substance administration for Resident #21, with delayed narcotic sign-out.
F0761: The facility failed to label and store drugs and biologicals properly, including insulin pens missing expiration dates.
F0804: Food served to residents was not palatable, flavorful, or at an appetizing temperature, with multiple resident complaints and documented food forum concerns.
F0805: The facility did not ensure food was prepared in a form consistent with physician-ordered diet consistencies for residents #3, #10, #23, #35, and #48, posing choking risks and safety concerns.
Report Facts
Weight loss: 6.7
Weight loss: 16
Activity minutes: 14
Activity minutes: 9
Activity minutes: 23
Activity minutes: 26
Activity minutes: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #4 | Registered Nurse | Observed administering narcotic medication without timely documentation |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Provided education on narcotic documentation expectations |
| Director of Nursing #1 | Director of Nursing | Provided statements on restraint use, narcotic documentation, hydration expectations, and food service issues |
| Licensed Practical Nurse Unit Manager #3 | Licensed Practical Nurse Unit Manager | Stated restraint assessment should be completed before using chair alarms |
| Director of Dietary Services #1 | Director of Dietary Services | Discussed food complaints and weight monitoring |
| Registered Dietitian #1 | Registered Dietitian | Discussed nutritional assessments, weight loss monitoring, and diet consistency issues |
| Certified Nurse Aide #4 | Certified Nurse Aide | Reported on activities and beverage offerings |
| Certified Nurse Aide #5 | Certified Nurse Aide | Observed serving incorrect meals and responding to resident complaints |
| Speech Language Pathologist #1 | Speech Language Pathologist | Provided assessments and recommendations on diet consistencies |
| Administrator #1 | Administrator | Discussed Food Forum and resident feedback process |
Inspection Report
Capacity: 60
Deficiencies: 14
Date: Mar 26, 2024
Visit Reason
Multiple Level 2 deficiencies in quality of care areas including activities, care plans, food, nutrition, pharmacy services, and physical restraints; all corrected by September 2024. Life Safety Code deficiencies also noted and corrected.
Findings
Multiple Level 2 deficiencies in quality of care areas including activities, care plans, food, nutrition, pharmacy services, and physical restraints; all corrected by September 2024. Life Safety Code deficiencies also noted and corrected.
Deficiencies (14)
Activities meet interest/needs each resident
Develop/implement comprehensive care plan
Food in form to meet individual needs
Infection control
Investigate/prevent/correct alleged violation
Label/store drugs and biologicals
Nutrition/hydration status maintenance
Nutritive value/appear, palatable/prefer temp
Pharmacy srvcs/procedures/pharmacist/records
Right to be free from physical restraints
Ep program patient population
Fire alarm system - installation
Means of egress - general
Roles under a waiver declared by secretary
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 12, 2024
Visit Reason
One Level 2 deficiency for reporting to national health safety network; not corrected at time of report.
Findings
One Level 2 deficiency for reporting to national health safety network; not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 6, 2024
Visit Reason
One Level 2 deficiency for reporting to national health safety network; not corrected at time of report.
Findings
One Level 2 deficiency for reporting to national health safety network; not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 30, 2024
Visit Reason
One Level 2 deficiency for reporting to national health safety network; not corrected at time of report.
Findings
One Level 2 deficiency for reporting to national health safety network; not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Feb 3, 2023
Visit Reason
One Level 2 deficiency for reporting of alleged violations; corrected by March 15, 2023.
Findings
One Level 2 deficiency for reporting of alleged violations; corrected by March 15, 2023.
Deficiencies (1)
Reporting of alleged violations
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 29, 2021
Visit Reason
One Level 2 deficiency for reporting to national health safety network; no correction noted.
Findings
One Level 2 deficiency for reporting to national health safety network; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Sep 21, 2021
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory standards for nursing home operations, including housekeeping, medication management, food safety, waste disposal, and infection control.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, proper labeling of medications, food preparation and sanitation standards, garbage disposal, and infection prevention and control practices, including failure to promptly test an employee exhibiting COVID-19 symptoms.
Deficiencies (5)
F 0584: The facility did not provide effective housekeeping and maintenance services, with soiled floors and peeling wallpaper observed in multiple resident rooms and units.
F 0761: Medications designed for multiple administrations, specifically insulin pens, were not labeled with the date they were opened as required by policy and manufacturer instructions.
F 0812: Food preparation and serving areas, including the main kitchen and kitchenettes, were not maintained in a clean condition and lacked an accurate sanitizer test kit.
F 0814: Garbage dumpsters were not maintained in a sanitary condition, with missing covers, leaking oily liquid, flies, and littered grounds observed.
F 0880: The facility failed to maintain an effective infection control program by not ensuring an employee exhibiting COVID-19 symptoms was promptly tested and removed from work.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DC #1 | Dietary Cook | Employee exhibiting COVID-19 symptoms not promptly tested |
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding medication labeling | |
| Registered Nurse (RN) #1 | Interviewed regarding medication labeling | |
| Assistant Director of Nursing (ADON) #1 | Assistant Director of Nursing | Interviewed regarding medication labeling and infection control follow-up |
| Food Service Director (FSD) | Food Service Director | Interviewed regarding food safety and employee symptom reporting |
| Administrator | Administrator | Interviewed regarding housekeeping, food safety, dumpster maintenance, and infection control |
| Director of Maintenance | Director of Maintenance | Interviewed regarding maintenance of peeling wallpaper |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding infection control policies and employee screening |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding housekeeping deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Apr 26, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with federal and state regulations for nursing home operation and resident care.
Findings
The facility was found deficient in multiple areas including resident dignity and conflict management, notification of Medicare coverage changes, baseline and comprehensive care planning, hydration, medication regimen reviews, unnecessary medication use, food safety, carbon monoxide detection, and infection control practices.
Deficiencies (11)
F 0550: The facility failed to ensure a resident was treated with dignity and respect, as staff did not address a resident-to-resident conflict causing the resident to avoid her room.
F 0582: The facility did not provide timely and specific notification to residents or representatives when Medicare Part A skilled services were no longer covered, lacking accurate information on options and appeal rights.
F 0655: The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, and did not provide documentation of care plan review with a resident's representative.
F 0656: The facility did not develop comprehensive care plans with measurable actions and time frames for two residents, including failure to implement safety interventions such as chair alarms consistently.
F 0692: The facility did not ensure adequate fluid intake was offered and provided to a resident, resulting in signs of dehydration and failure to update care plans accordingly.
F 0756: The facility lacked a policy with established time frames for monthly Medication Regimen Reviews and pharmacist actions on irregularities.
F 0757: The facility failed to ensure a resident's medication regimen was free from unnecessary medications, including lack of documentation for PRN pain medication administration and pain assessment.
F 0758: The facility failed to ensure psychotropic medications were only used when necessary with appropriate documentation, including lack of indication and symptom documentation for PRN Ativan use.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards, as expired and undated foods were found in unit kitchenettes.
F 0836: The facility failed to provide carbon monoxide detectors that were hardwired or powered by a 10-year battery as required by fire code regulations.
F 0880: The facility did not maintain an effective infection prevention and control program, failing to follow standard precautions during dressing changes and having inadequate written policies to prevent infection spread.
Report Facts
Residents reviewed for baseline care plans: 17
Residents reviewed for care plans: 19
Residents reviewed for hydration: 1
Residents reviewed for unnecessary medications: 5
Residents affected by dignity deficiency: 1
Residents affected by notification deficiency: 2
Residents affected by infection control deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed performing dressing change without proper infection control. |
| RN #5 | Registered Nurse | Interviewed regarding PRN medication administration and documentation. |
| RNM #4 | Registered Nurse Manager | Interviewed regarding medication administration and care plan expectations. |
| RNUM #4 | Registered Nurse Unit Manager | Interviewed about resident safety care plans and hydration issues. |
| ADON | Assistant Director of Nursing | Interviewed regarding infection control policy and dressing change practices. |
| Director of Nursing | Director of Nursing | Interviewed about resident conflict, care plan expectations, and safety interventions. |
| Food Service Director | Food Service Director | Interviewed regarding food storage and kitchenettes. |
| Director of Plant Operations | Director of Plant Operations | Interviewed regarding carbon monoxide detector compliance. |
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