Inspection Reports for
Elderwood at Hornell
One Bethesda Drive, N Hornell, NY, 14843
Back to Facility ProfileInspection Report — Feb 2, 2024
Complaint Investigation
Citations: 6
Date: Feb 2, 2024
Visit Reason
State-compiled facility profile showing 7 inspections from June 2022 to May 2026 with citation and complaint history.
Complaint Details
The state logged 153 complaints about this facility; 8 led to on-site inspections. One citation resulted from those complaints.
Findings
Across 7 inspections, 5 resulted in citations totaling 6 citations including 5 standard health and 1 life safety code citation. The facility had 153 complaints with 8 on-site inspections and no formal enforcement actions.
Citations (6)
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System.
Standard Health Citation — quality of care: Reporting - National Health Safety Network.
Standard Health Citation — quality of care: Reporting - National Health Safety Network.
Standard Health Citation — quality of care: Reporting - National Health Safety Network.
Standard Health Citation — quality of care: Reporting - National Health Safety Network.
Report Facts
Inspections on page: 7
Total violations/deficiencies cited: 6
Inspections with violations: 5
Inspections without violations: 2
Total complaints: 153
On-site complaint inspections: 8
Citations from complaints: 1
Total enforcement actions: 0
Inspection Report — Feb 2, 2024
Renewal
Citations: 1
Date: Feb 2, 2024
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with care planning and skin care requirements for residents.
Findings
The facility failed to develop and implement a complete care plan for Resident #16 that included measurable objectives and interventions addressing self-inflicted skin injuries. Observations and interviews revealed the resident had untreated skin scratches and sores, and the use of protective geri-sleeves was not implemented as ordered.
Citations (1)
F 0656: The facility did not develop and implement a care plan for Resident #16 that included measurable objectives and interventions for self-inflicted skin injuries. Protective geri-sleeves were not used as required, and documentation of skin conditions was lacking.
Report Facts
Residents reviewed for activities of daily living: 3
Physician order date: Oct 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Manager #1 | Provided information about Resident #16's skin condition and care planning | |
| Certified Nurse Assistant #1 | Observed Resident #16 scratching and applying lotion | |
| Director of Nursing | Stated nurses should document and care plan for Resident #16's scratching behavior |
Inspection Report — Oct 7, 2021
Annual Inspection
Citations: 4
Date: Oct 7, 2021
Visit Reason
The inspection was a Recertification Survey to assess compliance with regulatory requirements for nursing home care.
Findings
The survey identified multiple deficiencies including failure to implement and revise care plans for wheelchair positioning, inadequate environmental safety measures to prevent resident access to hazardous items, inaccurate public posting of nursing staff schedules, and lapses in infection prevention and control practices including improper use of PPE and lack of infection surveillance data.
Citations (4)
F 0657: The facility did not ensure the care plan was implemented or revised for Resident #69's wheelchair positioning needs, resulting in improper positioning and lack of staff intervention.
F 0689: The facility did not ensure the environment was free from accident hazards for Resident #84, who had a history of consuming nonfood items, with personal care products accessible and unsecured.
F 0732: The facility did not ensure that the daily posting of nursing staff responsible for resident care was accurate and up to date for public viewing.
F 0880: The facility failed to implement proper infection control practices including lack of transmission-based precautions for Resident #39 with MRSA and C-Diff, improper PPE use during COVID-19 staff testing, and absence of infection surveillance data for September 2021.
Report Facts
Residents reviewed: 7
Dates of observations: 3
Daily Staffing Sheets reviewed: 3
Vancomycin dosage: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Mentioned in relation to Resident #69's care plan and wheelchair positioning |
| RN #1 | Registered Nurse | Provided statements about Resident #69's condition and care |
| RN Manager (RNM) | Registered Nurse Manager | Discussed Resident #69's care plan and Resident #84's incident investigation |
| Director of Rehabilitation | Discussed Resident #69's positioning needs and therapy referrals | |
| LPN #1 | Licensed Practical Nurse | Documented Resident #84's wandering and personal care supply accessibility |
| Director of Nursing (DON) | Provided multiple interviews regarding staffing, infection control, and Resident #39's precautions | |
| RN #2 | Registered Nurse | Observed assisting with COVID-19 staff testing without proper PPE |
| Administrator | Discussed staffing sheet postings |
Inspection Report — Mar 22, 2019
Annual Inspection
Citations: 3
Date: Mar 22, 2019
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with regulatory requirements for Elderwood at Hornell nursing home.
Findings
The survey identified deficiencies including failure to address resident grievances related to food service, lack of a person-centered care plan for a resident's smoking habit, and inconsistent administration of tube feedings for two residents, resulting in potential risks to resident care and safety.
Citations (3)
F 0565: The facility did not act upon grievances of residents regarding food concerns in a timely or effective manner, with no documented resolutions or follow-up from Resident Council Meetings.
F 0656: The facility failed to develop a person-centered care plan with measurable objectives and timeframes for Resident #87's smoking habit until after observation during the survey.
F 0693: The facility did not provide appropriate treatment for two residents with feeding tubes, as the volume of tube feeding delivered was inconsistent with physician orders and lacked proper documentation of variances.
Report Facts
Residents reviewed for care planning: 26
Residents reviewed for tube feedings: 2
Opportunities with tube feeding volume variance: 15
Opportunities with tube feeding volume variance: 8
Opportunities with tube feeding volume variance: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager | RNM | Identified Resident #87 as smoker and initiated Smoking Safety Assessment and Care Plan |
| Licensed Practical Nurse #1 | LPN | Described tube feeding administration and documentation process for Resident #3 |
| Licensed Practical Nurse #2 | LPN | Checked tube feeding pump settings and described feeding schedule for Resident #44 |
| Diet Technician | Diet Technician | Reported that dietary staff do not review 24-hour tube feeding intakes; nursing is responsible |
| Director of Nursing | DON | Agreed to review nursing progress notes for tube feeding variances |
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