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Complaint Investigation

Elderwood At Ticonderoga

August 20, 2025 · Ticonderoga, NY · 101 Adirondack Drive
Citations 2
CMS Rating 2/5
Beds 84
Provider ID 335482
Healthcare Facility
Elderwood At Ticonderoga
Ticonderoga, NY  ·  View full profile →
Inspection Summary

ELDERWOOD AT TICONDEROGA in TICONDEROGA, NY — inspection on August 20, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0580
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Licensed Practical Nurse #1 was told by night nurse the catheter was not being replaced because there was no order, and they thought it should not be replaced due to the trauma caused by resident pulling it out with balloon inflated.

They stated they were not aware the physician was not called.

They would have called the on-call provider if resident had pulled the catheter out on their shift.Registered Nurse #4 was the nurse responsible for the care of Resident #1 at the time of the incident. On 8/05 2025 at 1:50 PM and 8/06/2025 at 11:50 AM, attempts to contact Registered Nurse #4 were unsuccessful.On 8/05/2025 at 3:52 PM, attempt to contact Medical Provider #1 was unsuccessful. 10 New York Codes Rule Regulations 415.3(e)(2)(ii)(b)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Elderwood at Ticonderoga

101 Adirondack Drive Ticonderoga, NY 12883

SUMMARY STATEMENT OF DEFICIENCIES

and they read it on the 24-hour report that is used for daily reporting of the unit.

They stated that the resident did not complain of any discomfort throughout the day.

Licensed Practical Nurse #1 stated that in any case that a resident pulled their Foley catheter out, staff should follow the physician's orders.

They stated that if there were no orders, staff should be contact a physician and following their directions.

They stated that they did not call the physician that day as the resident was not complaining of any discomfort.

During an interview on 8/05/2025 at 3:36 PM, Licensed Practical Nurse #1 stated that residents with foley catheters had orders for routine care of the residents' indwelling catheter.

They stated that the routine care of residents with indwelling catheters included cleaning the area of insertion of the catheter, making sure that the catheter is intact, and recording the color, consistency, and amount of urine.

Licensed Practical Nurse #1 reviewed the residents' electronic chart and stated there were no orders from the physician for the residents' indwelling catheter.Attempt to interview Medical Provider #1 were unsuccessful. 10 New York Codes and Rules and Regulations 415.12

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TICONDEROGA, NY, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ELDERWOOD AT TICONDEROGA or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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