Inspection Reports for
Elderwood of Uihlein at Lake Placid

185 Old Military Road, Lake Placid, NY, 12946

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Deficiencies (last 4 years)

Deficiencies (over 4 years) 17.5 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

243% worse than New York average
New York average: 5.1 deficiencies/year

Deficiencies per year

36 27 18 9 0
2019
2021
2023
2024

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 21 Date: Oct 2, 2024

Visit Reason
Complaint Survey with 15 health and 6 life safety code citations, mostly level 2 severity, all corrected by November 2024.

Findings
Complaint Survey with 15 health and 6 life safety code citations, mostly level 2 severity, all corrected by November 2024.

Deficiencies (21)
Activities daily living (adls)/mntn abilities
Care plan timing and revision
Comprehensive assessment after signifcant chg
Develop/implement comprehensive care plan
Dispose garbage and refuse properly
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Label/store drugs and biologicals
Organization and administration
Physical environment
Quality of care
Resident rights/exercise of rights
Resident self-admin meds-clinically approp
Respiratory/tracheostomy care and suctioning
Safe/clean/comfortable/homelike environment
Discharge from exits
Elevators
Exit signage
Fire alarm system - installation
Subdivision of building spaces - smoke barrie
Vertical openings - enclosure

Inspection Report

Annual Inspection
Deficiencies: 12 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.

Deficiencies (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
NameTitleContext
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

Abbreviated Survey
Deficiencies: 1 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.

Deficiencies (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
NameTitleContext
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

Capacity: 60 Deficiencies: 6 Date: Nov 7, 2023

Visit Reason
Covid-19 Survey with 6 life safety code citations, all level 2 severity and corrected by December 2023.

Findings
Covid-19 Survey with 6 life safety code citations, all level 2 severity and corrected by December 2023.

Deficiencies (6)
Cooking facilities
Electrical equipment - power cords and extens
Sprinkler system - installation
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Vertical openings - enclosure

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 3 Date: Mar 17, 2023

Visit Reason
Complaint Survey with 3 health citations related to alleged violations and care directives, mostly level 2 severity, some corrected by May 2023.

Findings
Complaint Survey with 3 health citations related to alleged violations and care directives, mostly level 2 severity, some corrected by May 2023.

Deficiencies (3)
Investigate/prevent/correct alleged violation
Reporting of alleged violations
Request/refuse/dscntnue trmnt;formlte adv dir

Inspection Report

Abbreviated Survey
Deficiencies: 3 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.

Deficiencies (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
NameTitleContext
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

Complaint Investigation
Capacity: 60 Deficiencies: 1 Date: Nov 29, 2021

Visit Reason
Covid-19 Survey with 1 health citation for reporting to national health safety network, level 2 severity, not corrected as of report.

Findings
Covid-19 Survey with 1 health citation for reporting to national health safety network, level 2 severity, not corrected as of report.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 1 Date: Nov 22, 2021

Visit Reason
Covid-19 Survey with 1 health citation for reporting to national health safety network, level 2 severity, not corrected as of report.

Findings
Covid-19 Survey with 1 health citation for reporting to national health safety network, level 2 severity, not corrected as of report.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Annual Inspection
Deficiencies: 6 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.

Deficiencies (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
NameTitleContext
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

Complaint Investigation
Capacity: 60 Deficiencies: 8 Date: Nov 19, 2021

Visit Reason
Complaint Survey with 7 health and 1 life safety code citations related to ADL care, care plans, drug regimen, accident hazards, food policy, pressure ulcer treatment, and electrical equipment testing, mostly level 2 severity, corrected by January 2022.

Findings
Complaint Survey with 7 health and 1 life safety code citations related to ADL care, care plans, drug regimen, accident hazards, food policy, pressure ulcer treatment, and electrical equipment testing, mostly level 2 severity, corrected by January 2022.

Deficiencies (8)
ADL care provided for dependent residents
Baseline care plan
Drug regimen review, report irregular, act on
Free of accident hazards/supervision/devices
Personal food policy
Treatment/svcs to prevent/heal pressure ulcer
Safe/clean/comfortable/homelike environment
Electrical equipment - testing and maintenanc

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 1 Date: Nov 15, 2021

Visit Reason
Covid-19 Survey with 1 health citation for reporting to national health safety network, level 2 severity, not corrected as of report.

Findings
Covid-19 Survey with 1 health citation for reporting to national health safety network, level 2 severity, not corrected as of report.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Annual Inspection
Deficiencies: 7 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.

Deficiencies (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
NameTitleContext
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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