Inspection Reports for
Elderwood of Lakeside at Brockport
170 West Avenue, Brockport, NY, 14420
Back to Facility ProfileCitations (last 4 years)
Citations (over 4 years)
4 citations/year
Citations are regulatory findings recorded during state inspections.
22% better than New York average
New York average: 5.1 citations/yearCitations per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 6
Date: Apr 2, 2025
Visit Reason
Multiple level 2 deficiencies related to quality of care and life safety code were identified and corrected.
Findings
Multiple level 2 deficiencies related to quality of care and life safety code were identified and corrected.
Citations (6)
ADL care provided for dependent residents
Infection control
Infection prevention & control
Quality of care
Treatment/devices to maintain hearing/vision
Sprinkler system - maintenance and testing
Inspection Report
Abbreviated Survey
Citations: 2
Date: Jan 8, 2025
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with safety measures to prevent resident elopement and ensure adequate supervision.
Findings
The facility failed to ensure adequate supervision and monitoring devices to prevent a cognitively impaired resident from eloping. Corrective actions were implemented including audits, staff education, and improved monitoring systems.
Citations (2)
F 0689: The facility did not ensure adequate supervision and monitoring devices to prevent Resident #6, who was cognitively impaired and at high risk for wandering, from eloping. The resident cut off their wander guard bracelet and left the facility unsupervised, resulting in a 40-minute elopement approximately 0.3 miles away.
Binders containing pictures of residents at risk for elopement were placed on all units, the basement, and in the kitchen area for staff awareness and remained current as of 01/08/2025.
Report Facts
Distance resident eloped: 0.3
Time resident missing: 40
Date of survey completion: Jan 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Documented Resident #6's elopement and related progress notes |
| Director of Nursing | Director of Nursing | Documented family notification and facility investigation; emailed Nurse Manager regarding 15-minute checks |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Documented observations related to Resident #6 and medication administration attempts |
| Registered Nurse Manager #1 | Registered Nurse Manager | Documented Resident #6's refusal to wear wander guard bracelet |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding Resident #6 elopement and search |
| Physical Therapist #1 | Physical Therapist | Interviewed about Resident #6's walking abilities and supervision needs |
| Administrator | Administrator | Interviewed regarding facility supervision failures and corrective actions |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 1
Date: Jan 8, 2025
Visit Reason
One level 2 deficiency related to accident hazards/supervision/devices was identified and corrected.
Findings
One level 2 deficiency related to accident hazards/supervision/devices was identified and corrected.
Citations (1)
Free of accident hazards/supervision/devices
Inspection Report
Annual Inspection
Citations: 2
Date: Jul 13, 2023
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with regulatory requirements for nursing home operations and resident safety.
Findings
The facility was found to have deficiencies related to unsafe medication practices, including leaving medications unsupervised at a resident's bedside and unsecured storage of medications in unlocked charting rooms across multiple units. These issues posed minimal harm or potential for actual harm to residents.
Citations (2)
F 0689: The facility failed to ensure that medications were not left unsupervised at Resident #51's bedside, despite policies requiring supervision or physician orders for self-administration. Resident #51 had multiple medications left unattended, and wandering residents could access the medications.
F 0761: The facility did not ensure that drugs and biologicals were securely stored. Multiple medications were observed in unlocked and unsupervised charting rooms on three residential units, accessible to staff and residents who wander.
Report Facts
Number of pills left unsupervised: 19
Number of residents who wander: 4
Number of residential units with unsecured medication storage: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Stated unit had four residents who wander and no assessments for self-administration of medication | |
| Director of Nursing (DON) | Provided statements on medication administration policies and expectations | |
| Regional Nurse Consultant | Described requirements for medication self-administration including physician orders and locked storage | |
| Licensed Practical Nurse (LPN) #2 | Explained reasons for leaving medication unsupervised during emergency and non-emergency situations | |
| Licensed Practical Nurse/Nurse Manager (LPN/NM) #1 | Described medication storage practices in charting rooms | |
| Registered Nurse Manager (RNM) | Explained medication disposal and storage procedures | |
| Registered Nurse #1 (2nd floor covering NM) | Commented on security of medication storage in charting room |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 4
Date: Jul 13, 2023
Visit Reason
Level 2 deficiencies related to accident hazards, drug labeling/storage, and life safety code issues were identified and corrected.
Findings
Level 2 deficiencies related to accident hazards, drug labeling/storage, and life safety code issues were identified and corrected.
Citations (4)
Free of accident hazards/supervision/devices
Label/store drugs and biologicals
Electrical systems - essential electric syste
Fire alarm system - testing and maintenance
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 1
Date: Jan 7, 2022
Visit Reason
One level 2 deficiency related to accident hazards/supervision/devices was identified and corrected.
Findings
One level 2 deficiency related to accident hazards/supervision/devices was identified and corrected.
Citations (1)
Free of accident hazards/supervision/devices
Inspection Report
Annual Inspection
Citations: 0
Date: Oct 15, 2021
Visit Reason
Annual inspection survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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