Ellicott Center for Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Ellicott Center for Rehabilitation and Nursing, in the surveyor’s own words.

• Actual harm, isolatedF760Feb 13, 2025

  Based on interview and record review conducted during a Complaint investigation (Complaint #NY00356490) during a Standard survey completed on 2/13/2025, the facility did not ensure that each resident was free from significant medication errors for one (1) (Resident #202) of four (4) residents reviewed for insulin medications. Specifically, Resident #202 did not receive scheduled insulin doses or have their blood glucose (sugar) monitored per the provider orders. On 10/6/2024. the resident was found unresponsive, nonverbal with a blood glucose of 579 (normal 60 - 110) which resulted in hospitalization for diabetic ketoacidosis (a life-threatening complication of diabetes that occurs when the body does not have enough insulin). […]

• No harm, potential for more than minimal, widespreadF755Feb 7, 2025

  Based on observation, interview, and record review conducted during an Abbreviated (#NY00351834) survey completed on 2/7/25, the facility did not provide pharmaceutical services to meet the needs of each resident and the facility did not ensure that drug records were in order and that an account of all controlled drugs are maintained and periodically reconciled for four (River View, Harbor View, City View, and Sky View) of four units. Specifically, on 8/19/24, 93 narcotic (medication used to treat moderate to severe pain) medications were unaccounted for on the River View unit. […]

• No harm, potential for more than minimal, widespreadF725Oct 4, 2023

  Based on observation, interview, and record review conducted during Complaint investigations (#NY00296344, #NY00320402 and #NY00297199) during the Standard survey completed on 10/4/23, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for four (River View, Sky View, Harbor View, and City View) of four resident care units. Specifically, the facility did not have adequate nursing staff based on the facility's established minimum numbers of staff for each shift. Additionally, there was a lack of sufficient nursing staff to get residents out of bed, pass medications timely and according to physician orders, and not meeting resident care needs (showers). […]

• No harm, potential for more than minimal, patternF804Feb 13, 2025

  Based on observation, interviews, and record review conducted during Complaint investigations (Complaint #s NY00359253 and NY00368473) during the Standard survey completed on 2/13/25, the facility did not ensure that food and drink was palatable, attractive and at a safe and appetizing temperature for three (Cityview, Skyview, and Harborview units) of four test trays. Specifically, food was served during meals at suboptimal temperatures and was not palatable. Residents #3, #55, #63, #65, #96, #104, and #203 were involved. […]

• No harm, potential for more than minimal, patternF755Oct 4, 2023

  Based on observation, interview and record review conducted during the Standard survey completed on 10/4/23, the facility did not provide pharmaceutical services to meet the needs of each resident and the facility did not ensure that drug records were in order and that an account of all controlled drugs is maintained and periodically reconciled for four (River View, Harbor View, City View and Sky View) of four units. Specifically, on the Riverview Unit Licensed Practical Nurse (LPN) #4 was observed to have pre-poured resident medications and two narcotic reconciliation books with the keys to a medication cart and narcotic cupboard were left unattended in the medication room. […]