Deficiency Index

Elderwood of Lakeside at Brockport

Brockport, New York · CCN 335569

17 surveys since 2011, and no finding has been recorded at harm level.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
56
Surveys
17
Harm or worse
0
Immediate jeopardy
0
The record, 2011–2025
’11’15’20’25
No harm recordedHarm or worseNot surveyed
Harm or worseNone

No finding on record has been cited at harm level or above.

Beyond CMS’s monthly file14/17

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
120
Ownership
For profit - Limited Liability company
Chain
ELDERWOOD
County
Monroe
Medicare-certified since
1976

CMS ratings

Overall
4
Health inspection
4
Staffing
1
Quality measures
5

CMS’s own Five-Star ratings.

Compared with similar facilities

Not shown for this facility: too few citations in window (n=8, floor 20).

Last survey on record

Apr 2, 2025

586 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day2.693.37
Registered-nurse hours per resident day0.65—
Annual nurse turnover68.5%47.0%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

No fines, payment denials or special-focus designation on the current CMS record.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD571.4%E228.6%F—
No harm, potential for minimalA—B—C—
CMS’s current file: 7 of the 56 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F6892×

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • F6771×

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • F6841×

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • F6851×

    Assist a resident in gaining access to vision and hearing services.

  • F7611×

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

In the surveyor’s words

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

  • No harm, potential for more than minimal, patternF677Apr 2, 2025

    Based on observations, interviews, and record review conducted during a Recertification Survey and complaint investigation (NY00365495) from 03/28/2025 to 04/02/2025, for two (2) (Resident #55 and #59) of nine (9) residents, the facility did not ensure residents who were unable to carry out activities of daily living (basic self-care tasks people perform regularly to maintain their well-being, such as bathing and nail care) received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #55 had not received a shower in four (4) weeks, had unshaved facial hair, and unclean hair and fingernails. Resident #59 had not received a shower in three (3) weeks, was unshaven, and was observed using their hands to eat with debris underneath their fingernails. […]

  • No harm, potential for more than minimal, patternF761Jul 13, 2023

    Based on observations, interviews, and record reviews conducted during the Recertification Survey from [DATE] to [DATE], it was determined that for three of three residential units the facility did not ensure that drugs and biologicals were securely stored. Specifically, multiple medications were observed stored in an unlocked and unsupervised charting room. This is evidenced by the following: The facility policy Medication Rooms on Nursing Units dated [DATE], included that medication rooms on the nursing units of the facility will be the areas where medications for residents are stored. The rooms will have included but not limited to adequate means for security. […]

  • No harm, potential for more than minimal, isolatedF684Apr 2, 2025

    Based on observations, interviews, and record review conducted during the Recertification Survey from 03/27/2025 to 04/02/2025, the facility did not ensure residents received care in accordance with professional standards of practice for 1 (Residents #55) of 21 residents reviewed. Specifically, Resident #55 had edema (swelling in the legs) to both legs and did not receive compression therapy per physician order and their comprehensive care plan did not include goals and interventions related to the resident's diagnosis of diabetes, chronic kidney disease, or edema. This is evidenced by the following: 1. […]

  • No harm, potential for more than minimal, isolatedF685Apr 2, 2025

    Based on interviews and record review conducted during the Recertification Survey from 03/27/2025 to 04/02/2025, for one (1)(Resident #55) of three (3) residents reviewed the facility did not provide proper treatment and assistive devices to maintain vision. Specifically, the facility did not ensure Resident #55 was seen by the facility medical provider in a timely manner after reporting changes in vision, did not make an appointment with the resident's eye doctor per medical provider recommendation, and did not ensure the resident made it to a scheduled eye doctor appointment. […]

  • No harm, potential for more than minimal, isolatedF880Apr 2, 2025

    Based on observations, interviews, and record review conducted during a Recertification Survey from 03/27/2025 to 04/02/2025, it was determined for one (1) (Resident #78) of seven (7) residents reviewed, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. Specifically, Resident #78 was on Enhanced Barrier Precautions (infection control measures used to reduce the spread of multidrug-resistant organisms and involves the use of gowns and gloves during high-contact resident care activities) due to having a wound, a nurse did not perform hand hygiene prior to entering the resident's room, did not wear gloves while handling a… […]

Read 20 findings in full →The most serious and the most recent: 20 of 56 on record.

Every survey on record

FindingsAt actual harm or above

  • Apr 2, 2025Standard and complaint4 findings
  • Jan 8, 2025Complaint1 finding
  • Jul 13, 2023Standard2 findings
  • Jan 7, 2022Complaint1 finding
  • Mar 12, 2019Standard7 findings
  • Oct 2, 2017Standard3 findings
  • Jul 29, 2016Standard8 findings
  • Aug 28, 2015Standard and complaint7 findings
Show the 9 earlier surveys
  • Jun 17, 2015Complaint1 finding
  • Apr 15, 2015Complaint2 findings
  • Aug 20, 2014Complaint1 finding
  • Jul 10, 2014Standard2 findings
  • Jul 26, 2013—1 finding
  • Jun 14, 2013—6 findings
  • Aug 27, 2012—3 findings
  • Oct 26, 2011—1 finding
  • Aug 25, 2011—6 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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