Elderwood at Ticonderoga: Catheter Care Failure Unreported - NY
That is what inspectors found when they arrived at Elderwood at Ticonderoga, a nursing home on Adirondack Drive in the Adirondack foothills of upstate New York. The inspection, triggered by a complaint, was completed August 20, 2025.
The incident itself happened before inspectors arrived. What they documented was the aftermath: a gap in basic medical notification that left a resident's injury unaddressed by any physician, and a night shift that had made a clinical decision, quietly, without involving anyone authorized to make it.
The night nurse's reasoning, as recorded in the inspection report, was that the catheter should not be replaced because of the trauma the resident had already suffered pulling it out with the balloon inflated. That is not an unreasonable concern. Reinserting a catheter after that kind of injury carries real risk. But the decision not to replace it, and not to call a doctor, were two different things. The nurse made both calls.
Licensed Practical Nurse #1, who came on after the night shift, learned from the outgoing nurse that the catheter had not been replaced and that no order existed to replace it. The LPN told inspectors they were not aware the physician had never been called. They said that if the resident had pulled the catheter out on their own shift, they would have called the on-call provider.
Nobody had.
Registered Nurse #4 was the nurse responsible for Resident #1 at the time of the incident. Inspectors tried to reach RN #4 on August 5, 2025, at 1:50 in the afternoon. No answer. They tried again the following morning, August 6, at 11:50 AM. Still no answer. The report does not indicate whether contact was ever made.
Inspectors also attempted to reach Medical Provider #1 on August 5 at 3:52 PM. That attempt was also unsuccessful.
The inspection report does not describe the resident's condition after the incident, does not say whether the resident experienced pain or bleeding or required any subsequent treatment, and does not identify whether anyone at the facility ever did contact a physician in the days between the incident and the inspection. What it says is that the physician was not called at the time, and that the nurse responsible for the resident could not be reached when investigators came looking for answers.
Pulling a catheter out with the balloon inflated, rather than deflated as it should be before removal, can tear urethral tissue. It is the kind of event that warrants at minimum a physician's assessment, if not an urgent one. The night nurse's decision to skip that call, and to frame it as a matter of avoiding further trauma, substituted nursing judgment for medical evaluation in a situation that called for both.
The deficiency was cited under New York Code of Rules and Regulations 415.3(e)(2)(ii)(b) and assigned a harm level of minimal harm or potential for actual harm, with few residents affected. In the federal inspection framework, that places it below the threshold for immediate jeopardy, the most serious classification. It does not mean nothing happened to the resident. It means inspectors assessed the documented risk as limited in scope.
CMS cited the deficiency as F0580, which covers the requirement that residents receive prompt notification to their physician when there is a significant change in condition or an accident that results in injury.
The facility's event ID is 335482.
What the report leaves open is the question of what the resident experienced between the moment the catheter came out and the moment, days later, when inspectors walked through the door. The night nurse made a judgment call. The physician never got to make one at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elderwood At Ticonderoga from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 4, 2026 · Our methodology
ELDERWOOD AT TICONDEROGA in TICONDEROGA, NY was cited for violations during a health inspection on August 20, 2025.
The inspection, triggered by a complaint, was completed August 20, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.