Deficiency Records for Elderwood at Ticonderoga

A list of the most recent deficiencies for Elderwood at Ticonderoga. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency	Type of Deficiency	Deficiency Date	Date Corrected	Resulted from a Complaint?
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	Health	2023-02-03	2023-03-15	Y
Have an enclosure around a vertical opening shaft.	Fire Safety	2021-09-23	2021-11-19	N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Fire Safety	2021-09-23	2021-11-01	N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Fire Safety	2021-09-23	2021-10-31	N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	Health	2021-09-23	2021-10-22	N
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.	Health	2021-09-23	2021-10-22	N
Provide and implement an infection prevention and control program.	Health	2021-09-23	2021-10-22	N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	Health	2021-09-23	2021-10-20	N
Dispose of garbage and refuse properly.	Health	2021-09-23	2021-10-20	N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	Health	2019-04-26	2019-06-25	N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	Health	2019-04-26	2019-06-25	N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	Health	2019-04-26	2019-06-25	N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Health	2019-04-26	2019-06-25	N
Provide enough food/fluids to maintain a resident's health.	Health	2019-04-26	2019-06-25	N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	Health	2019-04-26	2019-06-25	N
Ensure each resident?s drug regimen must be free from unnecessary drugs.	Health	2019-04-26	2019-06-25	N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	Health	2019-04-26	2019-06-25	N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	Health	2019-04-26	2019-06-25	N
Provide and implement an infection prevention and control program.	Health	2019-04-26	2019-06-25	N
Have exits that are accessible at all times.	Fire Safety	2019-04-26	2019-06-24	N
Have an enclosure around a vertical opening shaft.	Fire Safety	2019-04-26	2019-06-24	N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Fire Safety	2019-04-26	2019-06-24	N
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	Fire Safety	2019-04-26	2019-06-24	N
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.	Health	2019-04-26	2019-05-24	N
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Health	2017-07-28	2017-09-21	N
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Health	2017-07-28	2017-09-21	N
Store, cook, and serve food in a safe and clean way.	Health	2017-07-28	2017-09-21	N
Have an enclosure around a vertical opening shaft.	Fire Safety	2017-07-28	2017-09-21	N
Inspect, test, and maintain automatic sprinkler systems.	Fire Safety	2017-07-28	2017-09-21	N
Install corridor and hallway doors that block smoke.	Fire Safety	2017-07-28	2017-09-21	N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Fire Safety	2017-07-28	2017-09-21	N
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.	Fire Safety	2017-07-28	2017-09-21	N
Ensure proper usage of power strips and extension cords.	Fire Safety	2017-07-28	2017-09-21	N
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	Fire Safety	2017-07-28	2017-09-21	N

Deficiency Records for Elderwood at Ticonderoga

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