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 complaint investigations included allegations that residents were not receiving necessary assistance with activities of daily living, feeding tube care was inadequate, medication errors occurred including missed insulin doses, and food was served at inappropriate temperatures.

The facility failed to provide adequate assistance with activities of daily living for dependent residents, did not ensure feeding tube formulas were administered as ordered, had significant medication errors including missed insulin doses leading to hospitalization, and served food at suboptimal temperatures that was unpalatable to residents.

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.

The complaint investigations (#NY00324268, #NY00317844, #NY00296344, #NY00320402, #NY00297199) included allegations that the facility did not support resident shower preferences, failed to ensure effective discharge planning, and lacked sufficient nursing staff to meet resident needs.

The facility failed to promote resident self-determination regarding shower preferences for two residents, did not ensure effective discharge planning for two residents, and did not maintain sufficient nursing staff to meet resident care needs including timely medication administration, assistance with activities of daily living, and showering.

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.