Elderwood at Ticonderoga

In the surveyor’s words

From the most serious findings on record at Elderwood at Ticonderoga, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF692Jul 15, 2024

  Based on observation, record review, and interviews during a recertification survey, the facility did not ensure the provision of nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment, therapeutic diet, and preferences for 4 (Residents #3, #23, #24 and #63) of 5 residents reviewed. Specifically, Residents #3, #23, and #63 were not monitored for weight loss, assessed when significant weight loss occurred, and did not receive correct meals consistent with physician ordered diets and recommendations for meal/caloric intake. […]

• No harm, potential for more than minimal, widespreadF805Jul 15, 2024

  Based on observations, record review, and interviews during a recertification survey, the facility did not ensure food was prepared in a form designed to meet the individual needs for 5 of 5 residents (Residents #3, #10, #23, #35, and #48) reviewed for diet consistency. Specifically, the Resident #3, #10, #23, #35, and #48 received meals that were not consistent with their physician ordered diets. This is evidenced by: Cross-referenced to F692: Nutrition/Hydration The facility policy, Nutrition and Hydration Needs, last revised 7/19/2018, documented the Registered Dietitian or Diet Technician would assess the nutritional needs of each resident upon admission and as needed. […]

• No harm, potential for more than minimal, patternF804Jul 15, 2024

  Based on record review, observation, and interview during the recertification survey, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 test trays (the 7/09/2024 and 7/10/2024 lunch meals) reviewed. Specifically, food and beverages served to residents for the 7/09/2024 and 7/10/2024 lunch meals on the Adirondack and Patriot main Dining Room were not palatable. Additionally, multiple residents complained of food palatability during the monthly facility Food Forum meetings. This was evidenced by: Food Forum Meeting documentation included the following concerns: - On 5/06/2024 all residents in attendance stated the soups lacked consistency. Some items such as rice, pork chops, and chicken were dry. […]

• No harm, potential for more than minimal, patternF812Sep 23, 2021

  Based on observation, record review, and staff interview during the recertification survey, the facility did not maintain food preparation areas in accordance with professional standards for food service safety. Food preparation and serving areas and equipment are to be kept clean, and a test kit is to be provided to measure the parts per million (ppm) concentration of the solution used to sanitize equipment. Specifically, food contact equipment in the main kitchen and 3 of 3 kitchenettes were not clean, and an accurate test kit was not provided. This is evidenced as follows. The main kitchen and the kitchenettes were inspected on 09/19/2021 at 10:24 AM. […]

• No harm, potential for more than minimal, isolatedF580Aug 20, 2025

  Based on record review and interviews conducted during an abbreviated survey (Case #2577186), the facility did not ensure they immediately consulted with the resident's physician when there was a significant change in condition for one (1) (Residents #1) of one (1) resident reviewed for significant changes. Specifically, for Resident #1 the physician was not notified that the resident had pulled out the urinary catheter. This is evidenced by:The Facility's Policy and Procedure titled, Change in Resident Condition Assessment, last modified 4/12/2018, documented; A change of condition is defined as a major change in the resident's status that: 1. Is not self-limiting. 2. Impacts one or more areas of health status. 3. Requires review/revision of the care plan. […]