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
22
Citations on file
Rolling three-year window
4
Life Safety surveys
In the same window
4
Tags cited more than once
Across separate surveys
8
Inspection & testing records
Of the citations on file

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

Slippingmore citations at the latest survey than at its earlier surveys in the window.

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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Which alerts

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

  • F-0584 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.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in NY, and nationally. Surveyors differ markedly between states, so the NY figure is the meaningful one.

This facility22NY median13National median11
Citations on file over three years, compared
MeasureCitations
This facility22
Median facility in NY13
Median facility nationally11

Survey history

Citations at each Life Safety survey
62019-1132022-0452024-0982024-09
Citations at each Life Safety survey
Survey dateCitations
November 1, 20196
April 8, 20223
September 19, 20245
September 20, 20248

Most-cited tags

Most-cited tags at this facility
E-00092K-07122K-03722K-09182E-00371E-00041K-09211E-00061
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
E-0009Include a process for Emergency Preparedness collaboration.22024-09-19
K-0712Have simulated fire drills held at unexpected times.22024-09-20
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.22022-04-08
K-0918Have generator or other power source capable of supplying service within 10 seconds.22024-09-20
E-0037Establish staff and initial training requirements.12019-11-01
E-0004Develop and maintain an Emergency Preparedness Program (EP).12024-09-19
K-0921Ensure that testing and maintenance of electrical equipment is performed.12022-04-08
E-0006Conduct risk assessment and an All-Hazards approach.12024-09-19

What the citations cover

Citations by CMS category
  • Emergency Preparedness Deficiencies 9
  • Smoke Deficiencies 5
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Miscellaneous Deficiencies 2
  • Other 2
Citations by CMS category
CategoryCitations
Emergency Preparedness Deficiencies9
Smoke Deficiencies5
Gas, Vacuum, and Electrical Systems Deficiencies4
Miscellaneous Deficiencies2
Services Deficiencies1
Egress Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

September 20, 2024 — 8 citations

Citations issued on September 20, 2024
TagWhat the surveyor checksStatus
K-0271Have exits that are accessible at all times.Deficient, Provider has date of correction (November 18, 2024)
K-0311Have an enclosure around a vertical opening shaft.Deficient, Provider has date of correction (November 18, 2024)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (November 18, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (November 22, 2024)
K-0531Have elevators that firefighters can control in the event of a fire.Deficient, Provider has date of correction (November 15, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (November 18, 2024)
K-0914Ensure 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-0918Have 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

Citations issued on September 19, 2024
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (November 16, 2024)
E-0006Conduct risk assessment and an All-Hazards approach.Deficient, Provider has date of correction (November 16, 2024)
E-0007Address patient/client population and determine types of services needed.Deficient, Provider has date of correction (November 16, 2024)
E-0009Include a process for Emergency Preparedness collaboration.Deficient, Provider has date of correction (November 16, 2024)
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (November 16, 2024)

April 8, 2022 — 3 citations

Citations issued on April 8, 2022
TagWhat the surveyor checksStatus
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (June 6, 2022)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (June 6, 2022)
K-0921Ensure that testing and maintenance of electrical equipment is performed.Deficient, Provider has date of correction (June 6, 2022)

November 1, 2019 — 6 citations

Citations issued on November 1, 2019
TagWhat the surveyor checksStatus
E-0009Include a process for Emergency Preparedness collaboration.Deficient, Provider has date of correction (December 30, 2019)
E-0026Establish roles under a Waiver declared by secretary.Deficient, Provider has date of correction (December 30, 2019)
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (December 30, 2019)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (December 30, 2019)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (December 30, 2019)
K-0712Have 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.