Elderwood at Hornell

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident was free from physical abuse for one of four residents reviewed (Resident #60). Specifically, on 06/19/2026, facility staff used physical force to direct Resident #60 back to their room and intentionally restricted the resident's movement by preventing them from freely using their arms and moving away from staff for approximately 10 to 15 minutes after becoming agitated. Rather than implementing care planned behavioral interventions, staff continued restricting the resident's movement until they calmed, resulting in multiple bruises to both hands, wrists, left forearm, left upper arm, and a skin tear above the right elbow. This resulted in actual harm to Resident #60, that was not Immediate Jeopardy.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure an alleged violation involving physical abuse was immediately reported to facility administration and to the State agency as required for one of four residents reviewed (Resident #60). Specifically, Resident #60 was physically restrained by three staff members on 06/19/2026. The allegation was not reported to facility administration until 06/24/2026, approximately five days later, when Support Aide #1 disclosed the incident during a certified nursing assistant training class. After the Director of Nursing became aware of the allegation, the facility failed to report the allegation to the New York State Department of Health within two hours. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for two of two residents reviewed (Resident #11 and Resident #12). Specifically, Resident #11 required Enhanced Barrier Precautions (an infection prevention strategy requiring gowns and gloves during high-contact resident care activities) during wound care. Registered Nurse #1 failed to properly secure the required gown, allowed the gown to contact the wound area, and failed to change gloves and perform hand hygiene between providing care to two separate wounds. Resident #12 required Enhanced Barrier Precautions during wound care. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey it was determined that for one (Resident #16) of three residents reviewed for activities of daily living, the facility did not develop and implement a plan of care for the resident that included measurable objectives and interventions to address the resident's medical and physical needs. Specifically, Resident #16 had multiple scratches and sores on their right arm that were self- inflicted and had accumulated over time. The resident's Comprehensive Care Plan did not include the skin issues, the behavior creating the issues or interventions. Additionally, the use of geri-sleeves (protective arm covers) that was on the Certified Nurse Assistant [NAME] were not implemented on several observations. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for 1 (Resident #69) of 1 resident reviewed the facility did not ensure that the care plan was implemented and/or revised if appropriate to reflect the resident's current condition. The issue involved the lack of care plan implementation or revisions for therapy recommended wheelchair positioning. This is evidenced by the following: Resident #69 is a [AGE] year-old resident with diagnoses that include Alzheimer's disease, dementia, and chronic obstructive pulmonary disease. The Minimum Data Set assessment dated [DATE], documented that the resident had severe impairment cognitively, required extensive to total assistance with all activities of daily living and had functional limitation in range of motion on one side of the lower extremities. [...]

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey, completed on 10/7/21, it was determined that for one (Resident #84) of seven residents the facility did not ensure the environment remained as free of accident hazards as possible. Specifically, Resident #84 had a history of attempting to consume nonfood items and items were observed not properly stored to prevent a reoccurrence. This finding is: The facility policy Accident/Incident Reporting and Review (Staff/Visitors/Residents), dated 6/14/19, documented that staff are to report an Accident/Incident (A/I) involving a resident to the Unit Manager who fills out an A/I report and forwards it to the Director of Nursing (DON) or designee. The A/I plan of prevention is recorded on the Care Plan. Resident #84 had diagnoses including Alzheimer's disease, anxiety, and repeated falls. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, completed on 10/7/21, it was determined that the facility did not properly establish and maintain infection control practices to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable and transmission-based diseases and infections. Specifically, 1) the facility did not implement appropriate transmission-based precautions (TBP) for one (Resident #39) of two residents reviewed with a communicable disease, 2) A Registered Nurse (RN) did not wear appropriate Personal Protection Equipment (PPE) while assisting with COVID-19 staff testing, and 3) the facility did not have available any tracking/trending/surveillance of infections in the facility for September 2021. This is evidenced by the following: 1. [...]

Inspectors wroteBased on observation and interviews conducted during a Recertification Survey, completed on 10/7/21, it was determined that the facility did not ensure that the daily posting of nursing staff directly responsible for resident care was up to date and accurately reflected the required data at the beginning of each shift. Specifically, the information posted (where residents and families could view it) was not updated with changes in the schedule. This was evidenced by the following: During a review of the Daily Staffing Sheets (names and hours of nursing staff working each shift, including shifts 'open' or not yet filled yet) provided by the facility, dated 10/4/21- 10/6/21, and the posted nursing staffing information for residents and families to view per shift revealed the information did not match. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not act upon grievances of residents affecting resident care and life in the facility. Specifically, the facility did not address grievances brought up by the residents in Resident Council Meetings in a timely, thorough and effective manner or provide rationale for delay in response. This is evidenced by the following: Review of Resident Council Meeting minutes, from 9/4/18 through 2/4/19, consistently documented no new concerns; only food concerns that the Food Service Director will take care of. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 1 of 26 residents reviewed for care planning, the facility did not develop a person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, Resident #87 did not have a care plan developed for smoking. This is evidenced by the following: Resident #87 was originally admitted to the facility on [DATE], with diagnoses including end stage renal disease with dependence on renal dialysis, chronic obstructive pulmonary disease and nicotine dependence, cigarettes. The Minimum Data Set Assessment, dated 2/10/19, revealed the resident was cognitively intact. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #3 and #44) of two residents reviewed for tube feedings, the facility did not provide appropriate treatment and services to prevent complications. Specifically, the volume of tube feeding delivered in a 24-hour period was not consistent with the physician order. This is evidenced by the following: 1. Resident #3 was originally admitted to the facility on [DATE] with diagnoses including Rett's Syndrome (a rare neurological genetic disorder that causes severe muscle movement disability), dysphagia (difficulty swallowing), and gastrostomy status (external opening into the stomach for feeding tube placement). [...]