Inspection Reports for
Elderwood of Uihlein at Lake Placid
185 Old Military Road, Lake Placid, NY, 12946
Back to Facility Profile6 Reports
Inspection Report — Oct 2, 2024
Annual Inspection CMS
Date: Oct 2, 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 resident dignity and privacy, medication administration and labeling, care planning and assessments, infection control practices, food service cleanliness, garbage disposal, and respiratory care.
Citations (12)
F 0550: The facility failed to ensure treatment with respect, dignity, and care for residents, including administering insulin in a public area and lack of privacy when residents were observed disrobing in view of others.
F 0554: The facility did not assess a resident's ability to safely self-administer medications and lacked physician orders for self-administration of topical pain medications.
F 0584: The facility did not provide necessary maintenance services to maintain a clean, sanitary, comfortable, and homelike environment; roof leaks were observed in multiple areas.
F 0637: The facility failed to complete a Significant Change Minimum Data Set assessment for a resident after a fracture and loss of mobility.
F 0657: The facility did not timely review and revise care plans following significant events including a fall with fracture and resident-to-resident altercations.
F 0676: The facility failed to provide adequate and consistent interpreter services for a resident with limited English proficiency, resulting in communication barriers.
F 0684: The facility did not ensure a resident received an assessment by a qualified person upon return from hospital following a fracture.
F 0695: The facility failed to ensure oxygen tubing was labeled and dated when changed and that tubing was changed according to policy; some tubing was unlabeled or outdated.
F 0761: The facility did not ensure drugs and biologicals were labeled and stored according to professional standards; expired medications and improperly labeled insulin pens were observed.
F 0812: The facility did not ensure food service areas and equipment were clean; multiple kitchen appliances and surfaces were soiled with food particles and dust.
F 0814: The facility did not properly dispose of garbage and refuse; outdoor dumpster areas were littered and dumpsters were soiled.
F 0880: The facility failed to implement infection prevention and control practices consistently; staff did not use personal protective equipment properly and hand hygiene was inadequate.
Report Facts
Residents reviewed for dignity: 32
Residents affected by dignity deficiency: 3
Residents reviewed for medication self-administration: 32
Residents affected by medication self-administration deficiency: 1
Residents reviewed for oxygen administration: 2
Residents affected by oxygen tubing deficiency: 2
Medication carts reviewed: 3
Residents reviewed for care planning: 32
Residents affected by care planning deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #3 | Registered Nurse | Observed administering insulin in public area and interviewed about medication administration |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding medication administration policies, care planning, and infection control |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed about resident clothing and privacy expectations |
| Registered Nurse #1 | Registered Nurse | Interviewed about resident clothing and privacy expectations |
| Certified Nurse Aide #8 | Certified Nurse Aide | Interviewed about oxygen tubing changes and infection control practices |
| Certified Nurse Aide #9 | Certified Nurse Aide | Interviewed about oxygen tubing changes and infection control practices |
| Registered Nurse #2 | Registered Nurse | Interviewed about communication with limited English proficiency resident |
| Support Aide #10 | Support Aide | Observed and interviewed regarding infection control and PPE use |
| Registered Nurse #4 | Registered Nurse | Interviewed about hand hygiene and infection control |
| Certified Nurse Aide #11 | Certified Nurse Aide | Observed distributing meals and hand hygiene |
Inspection Report — Oct 2, 2024
Abbreviated Survey CMS
Date: Oct 2, 2024
Visit Reason
The survey was conducted as a recertification and abbreviated survey to assess compliance with care plan development and implementation requirements.
Findings
The facility failed to ensure that comprehensive person-centered care plans included measurable objectives and timeframes for one resident. A Certified Nurse Aide did not follow the resident's care plan by failing to apply Geri sleeves prior to care, resulting in a skin tear injury.
Citations (1)
F 0656: The facility did not develop and implement a complete care plan with measurable objectives and timeframes for Resident #42. The Certified Nurse Aide failed to apply Geri sleeves before care, causing a skin tear on the resident's arm.
Report Facts
Residents reviewed for comprehensive care plans: 31
Residents affected: 1
Incident date: Jul 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #8 | Certified Nurse Aide | Named in the finding for failing to apply Geri sleeves causing injury |
| Director of Nursing #1 | Director of Nursing | Provided statements regarding the deficiency and disciplinary actions |
Inspection Report — Oct 1, 2024
Complaint Investigation State
Date: Oct 1, 2024
Visit Reason
State-compiled facility profile showing 4 inspections from 2022 to 2026 with citation and complaint history, enforcement actions, and deficiency details.
Complaint Details
Facility received 208 total complaints with 4 on-site inspections resulting from complaints during the reporting period.
Findings
Across 4 inspections, 2 had no citations while 2 resulted in 26 total citations including 18 standard health and 8 life safety code violations. The facility had 208 complaints with 4 on-site inspections and 2 enforcement actions totaling $22,000 in fines.
Citations (24)
Standard Health Citation — quality of care: Activities Daily Living (adls)/mntn Abilities deficiency noted.
Standard Health Citation — quality of care: Care Plan Timing And Revision deficiency noted.
Standard Health Citation — quality of care: Comprehensive Assessment After Significant Change deficiency noted.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan deficiency noted.
Standard Health Citation — quality of care: Dispose Garbage And Refuse Properly deficiency noted.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve-sanitary deficiency noted.
Standard Health Citation — quality of care: Infection Prevention & Control deficiency noted.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals deficiency noted.
Standard Health Citation — quality of care: Organization And Administration deficiency noted.
Standard Health Citation — quality of care: Physical Environment deficiency noted.
Standard Health Citation — quality of care: Quality Of Care deficiency noted.
Standard Health Citation — quality of care: Resident Rights/exercise Of Rights deficiency noted.
Standard Health Citation — quality of care: Resident Self-admin Meds-clinically Appropriate deficiency noted.
Standard Health Citation — quality of care: Respiratory/tracheostomy Care And Suctioning deficiency noted.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment deficiency noted.
Life Safety Code Citation — NFPA requirements: Discharge From Exits deficiency noted.
Life Safety Code Citation — NFPA requirements: Elevators deficiency noted.
Life Safety Code Citation — NFPA requirements: Exit Signage deficiency noted.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Installation deficiency noted.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrier deficiency noted.
Life Safety Code Citation — NFPA requirements: Vertical Openings - Enclosure deficiency noted.
Standard Health Citation — quality of care: Investigate/prevent/correct Alleged Violation deficiency noted.
Standard Health Citation — quality of care: Reporting Of Alleged Violations deficiency noted.
Standard Health Citation — quality of care: Request/refuse/discontinue Treatment; formulate Advance Directive deficiency noted and not yet corrected.
Report Facts
Inspections on page: 4
Total violations/deficiencies cited: 26
Inspections with violations: 2
Inspections without violations: 2
Total complaints: 208
On-site complaint inspections: 4
Total enforcement actions: 2
Total fines: 22000
Inspection Report — Mar 17, 2023
Abbreviated Survey CMS
Date: Mar 17, 2023
Visit Reason
The survey was conducted as an abbreviated survey to investigate compliance with residents' rights to refuse treatment and to assess the facility's handling of abuse allegations and reporting requirements.
Findings
The facility failed to ensure the right to refuse treatment for one resident by initiating CPR despite a valid DNR order. Additionally, the facility did not report an allegation of abuse immediately as required and failed to protect the resident by not suspending the alleged abuser during the investigation.
Citations (3)
F 0578: The facility did not ensure the right to refuse treatment for Resident #1 by failing to confirm the resident's DNR status with the paper medical record prior to initiating CPR.
F 0609: The facility did not report an allegation of rape by Resident #4 immediately to the Director of Nursing or Administrator, delaying the required notification beyond 2 hours.
F 0610: The facility did not prevent further potential abuse by failing to suspend CNA #3 following an allegation of rape made by Resident #4, allowing the CNA to complete their shift on a different unit.
Report Facts
Residents reviewed for DNR status: 6
Residents reviewed for abuse: 6
Licensed and certified staff in-serviced: 85
Ancillary staff in-serviced: 41
Participants in Code Blue Flow sheet inservice: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Initiated CPR on Resident #1 without confirming DNR status and was coached on code status verification. | |
| RNS #1 | Registered Nurse Supervisor | Responded to code blue, led CPR efforts, and was coached on code status verification. |
| CNA #3 | Certified Nursing Aide | Alleged perpetrator in abuse allegation involving Resident #4; was not suspended immediately. |
| RNS #2 | Registered Nurse Supervisor | Received abuse allegation from CNA #3 and delayed reporting to DON; allowed CNA #3 to finish shift on different unit. |
| Director of Nursing | DON | Oversaw investigation, coached staff, and stated CNA #3 should have been suspended immediately. |
Inspection Report — Nov 19, 2021
Annual Inspection CMS
Date: Nov 19, 2021
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 housekeeping and maintenance, baseline care plan development, provision of activities of daily living (ADL) care, pressure ulcer care, fall prevention and supervision, and policies regarding food brought in by visitors.
Citations (6)
F 0584: The facility did not provide effective housekeeping and maintenance services, failing to ensure floors were clean on 3 of 3 resident units during the recertification survey.
F 0655: The facility did not develop and implement baseline care plans within 48 hours of admission for 3 of 11 residents reviewed, failing to meet professional standards of quality care.
F 0677: The facility did not ensure residents dependent on staff for ADL care received necessary incontinence care according to their care plans for 2 of 3 residents reviewed.
F 0686: The facility did not ensure a resident with pressure ulcers received timely assessment and treatment, delaying initiation of a treatment plan after discovery of an open area on the coccyx.
F 0689: The facility did not ensure a resident's environment was free from accident hazards and failed to provide adequate supervision to prevent falls, with 19 falls resulting in 2 fractures and inadequate fall risk reassessment and intervention implementation.
F 0813: The facility's policy regarding foods brought to residents by visitors did not include procedures to assist residents who need help accessing and consuming such foods.
Report Facts
Falls: 19
Residents reviewed for baseline care plans: 11
Residents reviewed for ADL care: 3
Residents reviewed for pressure ulcers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding baseline care plans, ADL care deficiencies, fall prevention, and care plan implementation. |
| Licensed Practical Nurse #1 | LPN | Reported observation of pressure ulcer and communication failures. |
| Administrator | Facility Administrator | Interviewed regarding housekeeping, fall prevention, and policy deficiencies. |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding toileting care and supervision challenges. |
| Certified Nursing Assistant #2 | CNA | Interviewed regarding toileting care and care plan adherence. |
| Licensed Practical Nurse #3 | LPN | Interviewed regarding ADL care and toileting schedules. |
| Certified Nursing Assistant #4 | CNA | Interviewed regarding supervision responsibilities and care plan communication. |
| Certified Nursing Assistant #5 | CNA | Interviewed regarding supervision and care plan communication. |
| Licensed Practical Nurse #4 | LPN | Interviewed regarding activities and supervision for Resident #37. |
Inspection Report — Aug 2, 2019
Annual Inspection CMS
Date: Aug 2, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for Elderwood of Uihlein at Lake Placid nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide timely written notification of transfer/discharge and bed hold policy to residents or their representatives, inadequate assistance for a resident to get out of bed for care and activities, failure to ensure a resident was positioned fully upright while eating, lack of gradual dose reductions for psychotropic medications, unsanitary food preparation and serving areas, and lapses in infection prevention and control practices.
Citations (7)
F 0623: The facility did not provide written notification of transfer/discharge with reasons to Resident #75 or their representative at the time of hospital transfer.
F 0625: The facility did not notify Resident #75 or their representative in writing of the bed hold policy upon hospital transfer.
F 0684: Resident #44 was not assisted out of bed for care, services, and activities for more than two months, contrary to the comprehensive care plan.
F 0689: Resident #54 was not positioned fully upright while eating, increasing risk due to swallowing difficulties.
F 0758: Resident #36 did not receive gradual dose reductions or documented contraindications for ongoing psychotropic medication use.
F 0812: Food preparation and serving areas and equipment were not clean or in good repair, and an accurate sanitizer test kit was not provided.
F 0880: Infection control lapses occurred during wound dressing changes and tracheostomy care, including failure to change gloves and wash hands.
Report Facts
Residents reviewed for hospitalization: 1
Residents reviewed for psychotropic medication: 5
Residents reviewed for care and treatment: 21
Residents affected by deficiencies: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #5 | Registered Nurse | Named in infection control deficiency for wound dressing and tracheostomy care |
| Director of Social Services | Responsible for transfer/discharge notification and bed hold policy; stated not providing written notices | |
| Director of Nursing | Responsible for oversight of notifications and medication management; acknowledged documentation gaps | |
| Assistant Administrator | Responsible for providing bed hold policy notice; acknowledged failure to provide notice | |
| Supervising Administrator | Stated written notifications should have been provided | |
| Certified Nurse Aide #3 | CNA | Provided care to Resident #44; noted resident was assisted out of bed initially |
| Certified Nurse Aide #2 | CNA | Provided care to Resident #44; noted resident did not refuse to get out of bed |
| Physical Therapist #7 | PT | Stated staff used mechanical lift for Resident #44 and resident had no therapy limitations |
| Director of Activities | DOA | Noted Resident #44 was not allowed out of bed for activities |
| Registered Nurse Unit Manager #4 | RNUM | Acknowledged Resident #44 should have been assisted out of bed |
| Director of Nutrition Services | Acknowledged food service deficiencies and planned corrective actions | |
| Speech Therapist | SLP | Recommended Resident #54 be seated fully upright while eating |
| Registered Nurse #2 | RN | Stated Resident #54 should have been positioned fully upright while eating |
| Infection Control RN #6 | RN | Stated gloves and handwashing should be used during tracheostomy care |
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