Inspection Reports for
Ellicott Center for Rehabilitation and Nursing

Complaint investigations revealed multiple deficiencies including environmental issues, resident care failures, medication errors, infection control breaches, and regulatory noncompliance.

The facility was found deficient in maintaining a safe, clean, and homelike environment, including inadequate temperature control and housekeeping. There were significant deficiencies in resident care such as failure to provide personal hygiene and grooming, improper feeding tube management, medication errors including missed insulin doses, inadequate dialysis care and communication, unsecured medication storage, unsafe food temperatures, lack of proper infection control practices including failure to use gowns and gloves as required, and failure to maintain and document care for peripherally inserted central catheters and dialysis treatments.

The state logged 289 complaints about this facility; 51 led to on-site inspections. Complaint surveys cited 19 citations resulting from complaints.

Across 26 inspections, 20 had no citations while 6 inspections resulted in 75 citations, including 40 standard health and 35 Life Safety Code citations. The facility had 289 complaints with 51 on-site inspections and 4 enforcement actions totaling $24,000 in fines.

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.

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.

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.

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.