Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ELDERWOOD AT NORTH CREEK
NORTH CREEK, NY · 82 certified beds · Last Life Safety survey September 20, 2024
CMS Certification Number 335429 · first certified October 1974
Ownership
Operated by ELDERWOOD · For profit - Limited Liability company
- Ownership changed January 22, 2018 (change of ownership)from ADIRONDACK TRI-COUNTY NURSING AND REHABILITATION CENTER INC
Position within NY
22 citations — more than 78% of the 593 certified nursing homes in NY. Compared within NY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 4.7. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: March 2026 to November 2026. This facility’s last Life Safety survey was September 2024. Facilities in NY are typically surveyed 18–25 months after the last one (median 22), measured over 523 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
9 of the 22 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 22 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in NY, and nationally. Surveyors differ markedly between states, so the NY figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 22 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 1, 2019 | 6 |
| April 8, 2022 | 3 |
| September 19, 2024 | 5 |
| September 20, 2024 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | 2 | 2024-09-19 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-09-20 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2022-04-08 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-09-20 |
| E-0037 | Establish staff and initial training requirements. | 1 | 2019-11-01 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2024-09-19 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2022-04-08 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2024-09-19 |
What the citations cover
- Emergency Preparedness Deficiencies 9
- Smoke Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Miscellaneous Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 9 |
| Smoke Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 20, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 22, 2024) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (November 15, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 18, 2024) |
September 19, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (November 16, 2024) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (November 16, 2024) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (November 16, 2024) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (November 16, 2024) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (November 16, 2024) |
April 8, 2022 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 6, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 6, 2022) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (June 6, 2022) |
November 1, 2019 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (December 30, 2019) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (December 30, 2019) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (December 30, 2019) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (December 30, 2019) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 30, 2019) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 30, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.