Inspection Reports for
Elderwood of Lakeside at Brockport
170 West Avenue, Brockport, NY, 14420
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 2, 2025
Visit Reason
The inspection was conducted as a Recertification Survey combined with a complaint investigation regarding failure to provide necessary assistance with activities of daily living, including bathing, shaving, and nail care for residents.
Complaint Details
The complaint investigation (NY00365495) was substantiated, finding that the facility failed to provide scheduled showers, shaving, and nail care to residents due to staffing shortages.
Findings
The facility failed to ensure that residents unable to perform activities of daily living received adequate grooming and personal hygiene care. Two residents were observed to have not received showers for multiple weeks, were unshaven, and had unclean fingernails, attributed to staffing shortages.
Deficiencies (1)
F 0677: The facility did not provide care and assistance for activities of daily living to residents unable to perform them independently. Resident #55 had not received a shower in four weeks, was unshaven, and had unclean hair and fingernails. Resident #59 had not received a shower in three weeks, was unshaven, and had long jagged fingernails with debris.
Report Facts
Weeks without shower: 4
Weeks without shower: 3
Number of residents affected: 2
Number of residents in complaint sample: 9
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 2, 2025
Visit Reason
The inspection was conducted as a Recertification Survey combined with a complaint investigation regarding the facility's compliance with care standards, including activities of daily living assistance, treatment adherence, vision care, and infection control.
Complaint Details
The complaint investigation (NY00365495) focused on inadequate assistance with activities of daily living, failure to provide ordered treatments, delayed vision care, and infection control breaches.
Findings
The facility failed to ensure residents received necessary assistance with activities of daily living such as bathing, shaving, and nail care, failed to provide prescribed compression therapy for edema, did not ensure timely vision care appointments, and did not maintain proper infection prevention practices during wound care.
Deficiencies (4)
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.
Report Facts
Days without shower: 28
Days without shower: 21
Missed tubigrip applications: 18
Missed eye appointment date: Mar 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Named in relation to failure to notice Resident #55's unshaven and unclean condition. | |
| Licensed Practical Nurse #1 | Responsible for nail care of diabetic residents and noted Resident #55's hygiene issues. | |
| Certified Nursing Assistant Unit Clerk #1 | Responsible for scheduling medical appointments and arranging transportation; failed to schedule or arrange transport for Resident #55's eye appointment. | |
| Registered Nurse Minimum Data Set Coordinator | Provided statements on care standards and treatment expectations. | |
| Director of Nursing | Provided statements on facility policies, staffing issues, and care deficiencies. | |
| Licensed Practical Nurse #2 | Failed to perform proper hand hygiene and glove changes during wound care for Resident #78. | |
| Nurse Practitioner #1 | Documented Resident #55's eye condition and need for follow-up. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 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.
Deficiencies (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
Deficiencies: 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.
Deficiencies (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
Deficiencies: 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.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Annual Inspection
Deficiencies: 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 multiple medications unsupervised at a resident's bedside and unsecured storage of drugs and biologicals in unlocked charting rooms across multiple residential units.
Deficiencies (2)
F 0689: The facility failed to ensure that Resident #51's environment was free from accident hazards by leaving approximately 19 pills unsupervised on the bedside table without assessment or care planning for safe self-administration of medication.
F 0761: The facility did not ensure that drugs and biologicals were securely stored, with multiple medications observed in unlocked and unsupervised charting rooms on three residential units.
Report Facts
Number of pills left unsupervised: 19
Number of residents wandering: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Stated unit had four residents who wander and none had been assessed for self-administration of medication |
| Director of Nursing | DON | Provided statements on medication administration policies and expectations |
| Regional Nurse Consultant | Explained requirements for medication self-administration including physician order and locked box | |
| Licensed Practical Nurse #2 | LPN | Explained medication left unsupervised due to emergency code blue and stated medications should never be left unsupervised |
| Licensed Practical Nurse/Nurse Manager #1 | LPN/NM | Described medication storage practices in charting room and acknowledged door sometimes left open |
| Registered Nurse Manager | RNM | Described medication disposal process and access to charting room |
| Registered Nurse #1 | RN | Commented on medication storage security and access to charting room |
Inspection Report
Annual Inspection
Deficiencies: 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.
Deficiencies (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
Deficiencies: 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.
Deficiencies (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
Deficiencies: 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.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Annual Inspection
Deficiencies: 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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