Inspection Reports for
Elderwood of Lakeside at Brockport

Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents was deficient with a pattern scope.

Standard Health Citation — quality of care: Infection Control was deficient with a pattern scope.

Standard Health Citation — quality of care: Infection Prevention & Control was deficient with an isolated scope.

Standard Health Citation — quality of care: Quality Of Care was deficient with an isolated scope.

Standard Health Citation — quality of care: Treatment/devices To Maintain Hearing/vision was deficient with an isolated scope.

Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing was deficient with a pattern scope.

Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices was deficient with an isolated scope.

Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices was deficient with an isolated scope.

Standard Health Citation — quality of care: Label/store Drugs And Biologicals was deficient with a pattern scope.

Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste was deficient with an isolated scope.

Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance was deficient with a pattern scope.

F 0677: The facility did not ensure residents unable to perform activities of daily living received necessary grooming and hygiene services. Resident #55 had not showered in four weeks and had unshaven facial hair and unclean hair and fingernails. Resident #59 had not showered in three weeks, was unshaven, and had debris under fingernails.

F 0684: Resident #55 with edema did not receive prescribed daily tubigrip compression therapy consistently, and the care plan lacked goals and interventions related to edema and chronic conditions.

F 0685: The facility did not ensure Resident #55 was seen timely by the medical provider for vision changes, did not schedule an earlier eye appointment, and missed the scheduled eye doctor appointment due to lack of transportation arrangements.

F 0880: Licensed Practical Nurse #2 failed to perform hand hygiene and glove changes during wound care for Resident #78, risking contamination of a stage three pressure ulcer.

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.

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.