Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elderwood At Ticonderoga during CMS and state inspections, most recent first.
A resident with multiple complex diagnoses pulled out their urinary catheter, resulting in blood on the bedding. Facility staff did not document or notify the physician of this significant change in condition, as required by policy. Interviews revealed that staff were unaware if the provider had been contacted, and the incident was not recalled by administration or the DON.
A resident with an indwelling Foley catheter and multiple comorbidities did not receive appropriate catheter care due to the absence of physician orders and lack of documentation. After the resident self-removed the catheter, staff failed to notify a provider or monitor urine output, and there was no evidence that care protocols or facility policies were followed.
The facility failed to provide adequate nutritional and hydration care to residents, resulting in significant weight loss and dehydration risks. A resident experienced a 6.7% weight loss over three months without proper assessment, and another lost 16% of their weight over four months due to incorrect meal consistency and missing supplements. Additionally, a resident with Parkinson's disease was not monitored for dehydration, with drinks only provided during meals. The facility's policies on nutrition and hydration were not effectively implemented, and staff communication was lacking.
The facility failed to provide meals consistent with the dietary needs of residents, as evidenced by several instances where residents with dysphagia and other conditions were served meals that did not match their prescribed diet consistencies. This included serving meals with inconsistent textures and sizes, leading to potential risks for choking and weight loss. Despite staff training, the facility did not consistently prepare meals according to physician orders.
The facility failed to provide palatable and appetizing meals, as observed during a survey. Residents reported dissatisfaction with the quality and taste of food, citing issues such as blandness and toughness. The Director of Dietary Services acknowledged the complaints, attributing them to a change in vendors and new menus.
A resident with severe cognitive impairment was found with a chair alarm on their wheelchair, despite facility policy requiring an assessment before using such devices. The alarm was not documented in the care plans or medical orders, and staff interviews revealed a misunderstanding of its classification as a restraint.
A resident with severe cognitive impairment and other health issues had a chair alarm on their wheelchair, but the facility failed to document this in the comprehensive care plan. The facility's policy required such interventions to be included in the care plan, but this was not done, as confirmed by the DON.
The facility failed to provide an ongoing activities program that met the needs of two residents, one with severe dementia and another with Parkinson's disease and depression. Observations showed these residents often sat alone without engagement, and activity logs revealed inconsistent participation. Staffing issues contributed to the deficiency, as the facility could not run simultaneous activities across units.
A registered nurse in an LTC facility administered clonazepam to a resident without documenting it on the narcotic inventory sheet as required by policy. The nurse admitted to delaying documentation, which was against the facility's expectations. Interviews with nursing staff confirmed the need for immediate documentation of narcotic administration.
During a survey, it was found that a medication cart contained an opened Basaglar Kwik insulin pen labeled only with the date it was opened, missing the expiration date. Interviews with staff, including an LPN, RN Supervisor, and DON, confirmed that the pen should have been labeled with both dates, highlighting a failure to adhere to labeling protocols.
A resident with severe cognitive impairment was found with bruising around their right eye, but the LTC facility failed to conduct a timely investigation. Despite policies requiring immediate action, the incident was not documented or investigated until months later, based on a nurse's recollection. Interviews with staff confirmed the lack of documentation and investigation, highlighting a failure to determine the root cause and rule out abuse.
Failure to Notify Physician After Resident Pulled Out Urinary Catheter
Penalty
Summary
The facility failed to immediately notify the physician when a resident experienced a significant change in condition, specifically after the resident pulled out their urinary catheter. According to the facility's policy, staff are required to document changes in condition and contact the physician to determine the need for medical intervention. In this case, the resident, who had diagnoses including acute pyelonephritis, multiple sclerosis, and stage four chronic kidney disease, was found with the catheter removed and blood on the bedding. There was no documentation in the medical record that the physician was notified of this incident, despite the care plan indicating the provider should be updated as needed. Interviews with facility staff revealed that the nurse assigned to the resident at the time of the incident was no longer employed, and attempts to confirm whether the physician had been contacted were unsuccessful. Other nursing staff were unaware if the physician had been notified and indicated that the catheter was not replaced due to the trauma caused by its removal. The administrator and DON did not recall the incident, and the on-call provider service could not confirm if they had been contacted. The lack of documentation and communication with the physician following the significant change in the resident's condition constituted the deficiency.
Failure to Provide Appropriate Catheter Care and Physician Notification
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including acute pyelonephritis, multiple sclerosis, and stage four chronic kidney disease, was admitted with an indwelling Foley catheter. The facility failed to ensure that appropriate care and services were provided in accordance with professional standards of practice. There was no documented evidence that catheter care was provided, and physician orders for the care, maintenance, or replacement of the Foley catheter were absent. The resident's care plan indicated the need for daily catheter care and monitoring, but these interventions were not supported by corresponding physician orders or documentation of care provided. The situation escalated when the resident self-removed the Foley catheter with the balloon still inflated, resulting in bleeding. The facility physician was not notified of this significant change in condition, and there was no documentation of monitoring the resident's urine output or assessment following the incident. Interviews with nursing staff revealed a lack of communication and follow-through regarding physician notification and care protocols, with staff indicating that they did not contact a provider due to the absence of specific orders and the resident not expressing discomfort. Facility policies for catheter care were in place but did not address unintended catheter removal, and there was no evidence that these policies were followed in this case.
Inadequate Nutritional and Hydration Care
Penalty
Summary
The facility failed to provide adequate nutritional and hydration care to several residents, as observed during a recertification survey. Residents were not monitored for weight loss, and significant weight loss was not assessed or addressed. For instance, Resident #3 experienced a 6.7% weight loss over three months, yet the Registered Dietitian was unaware of this trend and had not assessed the resident. The resident's meal did not meet the ordered diet consistency, posing a choking risk. Similarly, Resident #23 experienced a 16% weight loss over four months, and their meals often did not meet the prescribed mechanical soft ground diet, lacking necessary supplements like cottage cheese and Magic Cups. Resident #24, diagnosed with Parkinson's disease and dementia, was not monitored for dehydration, and beverages were not offered throughout the day. Observations showed that the resident was only provided drinks during meals, and staff did not offer beverages between meals. The resident expressed a desire for more activities and reported having to yell to get staff attention, indicating a lack of engagement and monitoring by the staff. The resident's dry tongue suggested dehydration, yet no drinks were available outside of mealtimes. The facility's policies on nutrition and hydration were not effectively implemented, as evidenced by the lack of monitoring and appropriate dietary interventions for residents at risk of weight loss and dehydration. The Registered Dietitian, who was new to the facility, had not reviewed weight reports or assessed residents with significant weight loss. The Director of Dietary Services was responsible for monitoring weight loss but did not effectively communicate these issues to the Registered Dietitian. Additionally, the facility's hydration protocol was not consistently applied, and staff relied on activities personnel to provide drinks, which was insufficient for residents' hydration needs.
Failure to Provide Meals Consistent with Dietary Needs
Penalty
Summary
The facility failed to ensure that meals were prepared in a form designed to meet the individual dietary needs of residents, as evidenced by the experiences of five residents. Resident #3, who had dysphagia and was on a regular diet with easy-to-chew consistency, was served a meal with baked ham that had inconsistent shapes and sizes, and a dinner roll with mixed textures. The Registered Dietitian noted that the meal was not correct for the ordered consistency, and the resident had to tear the ham into smaller pieces themselves. Resident #23, who was on a mechanically altered diet, was served meals that did not match their dietary requirements. On one occasion, the resident was served instant mashed potatoes instead of the ordered mashed sweet potato and green beans that were too tough to chew. The resident reported frequent instances of receiving meals that were not the correct consistency, leading to weight loss and difficulty eating. The Speech Language Pathologist and Director of Dietary Services confirmed that the meals served were not prepared to the required consistency, posing a risk for choking or aspiration. Resident #48, with severe cognitive impairment and dysphagia, was served whole turkey meat and a dinner roll with mixed textures, contrary to their dietary needs for easy-to-chew meals. The Registered Dietitian emphasized that meals should be easy to chew and not have mixed consistencies. Despite training provided to staff on recognizing correct diet consistencies, the facility failed to consistently prepare and serve meals according to physician orders, resulting in potential risks to the residents' safety and nutrition.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable, flavorful, and at an appetizing temperature during the recertification survey. This deficiency was identified through record review, observation, and interviews. Specifically, the lunch meals served on two consecutive days in the Adirondack and Patriot main Dining Rooms were found to be unpalatable. Residents had previously expressed concerns about the quality of food during monthly Food Forum meetings, citing issues such as dry meats, lack of consistency in soups, and requests for more robust flavors and accompaniments like gravy and butter. Observations during the survey revealed that the test trays provided contained food that was bland, tough, and unappetizing. Residents interviewed also expressed dissatisfaction with the meals, noting that the food was not good, salty, and did not appear appetizing. The Registered Dietitian, who was new to the position, was unaware of the complaints, while the Director of Dietary Services acknowledged the issues and attributed them to a change in vendors and new menus. The Administrator confirmed the existence of a separate Food Forum for residents to provide feedback on meals.
Failure to Conduct Restraint Assessment for Chair Alarm
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints unless needed for medical treatment. Specifically, a chair alarm was observed on the wheelchair of a resident diagnosed with dementia with mood disturbance, a stroke, and generalized muscle weakness. The resident's Minimum Data Set indicated severe cognitive impairment, yet it documented that the resident did not have a chair alarm. The facility's policy required an interdisciplinary physical assessment before using a physical restraint, but no such assessment was documented for the chair alarm. Observations on two separate occasions confirmed the presence of the chair alarm on the resident's wheelchair. The Comprehensive Care Plan, Certified Nurse Aide care plan, and Medical Doctor orders lacked documentation of the chair alarm. Interviews with facility staff revealed that a restraint assessment should have been completed before using the chair alarm, but it was not considered a restraint by the Director of Nursing. This oversight led to the deficiency, as the facility did not adhere to its policy regarding the use of physical restraints.
Failure to Document Chair Alarm in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically regarding the use of a chair alarm. The resident, who was admitted with diagnoses including dementia with mood disturbance, a stroke, and generalized muscle weakness, was observed to have a chair alarm on their wheelchair. However, the comprehensive care plan did not document the use of this chair alarm, nor was it included in the Certified Nurse Aide care plan. The deficiency was identified during a recertification survey, where it was noted that the facility's policy required the interdisciplinary team to create a care plan that included measurable objectives and timeframes to meet the resident's needs. Despite this policy, the care plan for the resident did not reflect the use of the chair alarm, which was intended as an intervention to prevent falls. The Director of Nursing confirmed that the use of chair alarms should be documented in the care plan, indicating a lapse in adherence to the facility's care planning procedures.
Deficiency in Resident Activities Program
Penalty
Summary
The facility failed to provide an ongoing activities program that met the interests and supported the physical, mental, and psychosocial well-being of residents, as evidenced by the lack of activities provided to two residents, Resident #10 and Resident #24. Resident #10, who was admitted with severe dementia, anorexia, and failure to thrive, was observed multiple times sitting alone in a wheelchair without any activities being offered. The activity logs for May 2024 showed significant gaps in activity participation, with some days having no documented activities at all. Similarly, Resident #24, who had Parkinson's disease, dementia, and major depressive disorder, was also observed sitting alone without engagement in activities. The activity logs for Resident #24 indicated inconsistent participation, with several days lacking any documented activities. Despite the resident expressing a desire for more interaction and activities, the facility did not provide adequate opportunities for engagement, as observed during the survey. Interviews with staff revealed that the facility's activities program was hindered by staffing issues, specifically the departure of a staff member responsible for activities on the Adirondack Unit. This staffing shortage made it difficult to run simultaneous activities across different units, leading to a lack of engagement for residents who could not self-propel to the main activity area. The facility's failure to adhere to its own policy on providing a comprehensive activities program contributed to the deficiency identified during the survey.
Failure to Document Narcotic Administration Timely
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of drugs according to professional standards for one resident. During a recertification survey, it was observed that a registered nurse administered a controlled substance, clonazepam, to a resident without documenting the administration on the narcotic inventory sheet as required by the facility's Medication Administration Policy and Procedure. The nurse admitted to delaying the documentation of narcotic administration until they had free time, which is contrary to the policy that mandates immediate documentation. Interviews with the nursing staff, including a registered nurse supervisor and the director of nursing, confirmed that the expectation was for narcotic administration to be documented at the time of administration. The supervisor acknowledged awareness of the incident and had conducted a mini-education session with staff to emphasize the importance of timely documentation. The director of nursing reiterated that narcotic counts should be conducted at every shift change and that delaying documentation was inappropriate.
Improper Labeling of Insulin Pen
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards of practice, as observed during a recertification survey. Specifically, one of the two medication carts reviewed contained an opened Basaglar Kwik insulin pen that was labeled with the date it was opened but did not include the expiration date. This omission was contrary to the facility's policy, which requires checking medication expiration dates prior to administration, although no specific policy was provided regarding labeling insulin pens with both the opened and expiration dates. Interviews with staff members, including a Licensed Practical Nurse, a Registered Nurse Supervisor, and the Director of Nursing, confirmed that the expectation was for insulin pens to be labeled with both the date opened and the expiration date. The failure to properly label the insulin pen was acknowledged by the staff, indicating a lapse in adherence to labeling protocols. This deficiency was noted under the New York Codes, Rules and Regulations 415.18(d).
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough and accurate investigation following an injury of unknown origin observed in a resident. Resident #48, who has severe cognitive impairment and was admitted with diagnoses including unspecified dementia and dysphagia, was found with bruising around their right eye. Despite the facility's policy requiring immediate reporting and investigation of such incidents, no investigation was conducted at the time of the injury. The incident was only documented months later, based on the recollection of a registered nurse, who noted the bruise could have been self-inflicted but did not document their initial assessment. Interviews with facility staff revealed that the incident was not properly documented or investigated. The Nursing Home Administrator and Director of Nursing confirmed the lack of an investigation and documentation in the resident's electronic medical record. The registered nurse involved admitted to not documenting their assessment and assumed another nurse had done so. The Director of Nursing emphasized the importance of immediate investigation to determine the root cause and rule out abuse, which was not done in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ticonderoga
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Helen Porter Healthcare & Rehab | 17 mi | ★★★★★ | 5 | 0 |
| Essex Center For Rehabilitation And Healthcare | 26.5 mi | ★★★★★ | 0 | 0 |
| Slate Valley Center For Rehabilitation And Nursing | 27.8 mi | ★★★★★ | 0 | 0 |
| Rutland Healthcare & Rehabilitation Center | 28.4 mi | ★★★★★ | 0 | 0 |
| Elderwood At North Creek | 29.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Elderwood At Ticonderoga.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.