Inspection Reports for
Ellicott Center for Rehabilitation and Nursing

Multiple standard health and life safety code citations were identified, including issues with ADL care, dialysis, infection control, medication labeling, and building safety features. Deficiencies were mostly level 2 severity and corrected by mid-2025.

The facility failed to provide pharmaceutical services meeting residents' needs and did not maintain accurate drug records or properly reconcile controlled drugs across four units. Multiple narcotic medications were unaccounted for, medication room security was compromised due to malfunctioning keypad and broken locks, and narcotic reconciliation was often performed alone without proper shift-to-shift verification.

One isolated level 2 standard health citation related to pharmacy services and procedures was identified and corrected by May 8, 2025.

Complaint #NY00359366 triggered the abbreviated survey. The complaint involved failure to honor advance directives for Resident #1. The complaint was substantiated as the facility did not ensure the resident's DNR wishes were followed.

The facility failed to ensure that Resident #1's advance directive wishes were honored when cardiopulmonary resuscitation (CPR) was erroneously initiated despite a valid Medical Orders for Life Sustaining Treatment (MOLST) form indicating DNR and DNI status. The error occurred because Licensed Practical Nurse #1 reviewed the wrong resident's MOLST form and failed to verify the resident's identity prior to initiating CPR. Corrective actions were implemented including staff reeducation and audits.

One isolated level 2 standard health citation related to treatment refusal and advance directives was identified and corrected by November 11, 2024.

Complaint investigations #NY00324268, #NY00317844, #NY00296344, #NY00320402, and #NY00297199 were conducted addressing multiple resident care and facility operation concerns.

The facility was found deficient in multiple areas including failure to promote resident self-determination regarding shower preferences, failure to notify representatives of significant changes, unsafe environment due to cigarette smoking in shower room, ineffective discharge planning, inadequate assistance with activities of daily living, failure to provide treatment and care per orders, inadequate staffing levels impacting resident care, and improper pharmaceutical services including medication administration and narcotic reconciliation.

Multiple isolated and pattern level 2 standard health and life safety code citations were identified including ADL care, discharge planning, accident hazards, pharmacy services, quality of care, nursing staff sufficiency, and building safety features. All deficiencies were corrected by November 21, 2023.

One isolated level 2 standard health citation related to quality of care was identified and corrected by March 8, 2023.

Multiple isolated level 2 standard health citations related to abuse policies, abuse prevention, investigation, and reporting were identified and corrected by March 8, 2023.

One isolated level 2 standard health citation related to Covid-19 testing for residents and staff was identified and corrected by December 21, 2021.

The facility was found deficient in multiple areas including residents' access to personal funds, environmental cleanliness, investigation of abuse allegations, provision of appropriate care for limited range of motion, respiratory care, timely physician order signatures, psychotropic medication management, garbage disposal, infection control practices, and quality assurance processes.