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ELLICOTT CENTER FOR REHABILITATION AND NURSING Inspection Report, Violations & Safety Grade (BUFFALO, New York)

200 SEVENTH STREET, BUFFALO, New York 14201

Phone: 7168472500

CMS Overall:1/5

Overview & Bed Count

Certified Beds

160

Avg Residents/Day

153.5

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Erie

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall1/5

Health1/5

Staffing2/5

Quality2/5

Nurse Staffing Check

Metric	This Facility	New York Avg	Difference
RN Hours per Resident per Day	0.39	0.73	-0.34
Total Nurse Hours per Resident per Day	3.54	3.69	-0.15
CMS Staffing Rating	2/5	2.9/5	-
Nursing Staff Turnover	59.1%	40.3%	-

Health Citation History

33 health citations on record

Date	Category	Description	Severity
2025-02-13	Pharmacy Service Deficiencies	Ensure that residents are free from significant medication errors.	G – Actual Harm
2025-02-13	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	E – Moderate Harm Potential
2025-02-13	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	D – Moderate Harm Potential
2025-02-13	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2025-02-13	Quality of Life and Care Deficiencies	Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	D – Moderate Harm Potential
2025-02-13	Quality of Life and Care Deficiencies	Provide for the safe, appropriate administration of IV fluids for a resident when needed.	D – Moderate Harm Potential
2025-02-13	Quality of Life and Care Deficiencies	Provide safe, appropriate dialysis care/services for a resident who requires such services.	D – Moderate Harm Potential
2025-02-13	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	D – Moderate Harm Potential
2025-02-13	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2025-02-13	Administration Deficiencies	Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.	C – Minimal Harm Potential
2025-02-13	Resident Assessment and Care Planning Deficiencies	Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.	B – Minimal Harm Potential
2025-02-13	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	B – Minimal Harm Potential
2025-02-07	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	F – Moderate Harm Potential
2024-11-13	Resident Rights Deficiencies	Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.	D – Moderate Harm Potential
2023-10-04	Nursing and Physician Services Deficiencies	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	F – Moderate Harm Potential
2023-10-04	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	E – Moderate Harm Potential
2023-10-04	Resident Rights Deficiencies	Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	D – Moderate Harm Potential
2023-10-04	Resident Rights Deficiencies	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	D – Moderate Harm Potential
2023-10-04	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	D – Moderate Harm Potential
2023-10-04	Resident Assessment and Care Planning Deficiencies	Plan the resident's discharge to meet the resident's goals and needs.	D – Moderate Harm Potential
2023-10-04	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2023-10-04	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2023-10-04	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2021-09-22	Nursing and Physician Services Deficiencies	Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.	E – Moderate Harm Potential
2021-09-22	Pharmacy Service Deficiencies	Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	E – Moderate Harm Potential
2021-09-22	Administration Deficiencies	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	E – Moderate Harm Potential
2021-09-22	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	D – Moderate Harm Potential
2021-09-22	Quality of Life and Care Deficiencies	Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	D – Moderate Harm Potential
2021-09-22	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2021-09-22	Nutrition and Dietary Deficiencies	Dispose of garbage and refuse properly.	D – Moderate Harm Potential
2021-09-22	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2021-09-22	Resident Rights Deficiencies	Honor the resident's right to manage his or her financial affairs.	B – Minimal Harm Potential
2021-09-22	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	B – Minimal Harm Potential

Fire Safety Citation History

30 fire safety citations on record

Date	Category	Description	Severity
2025-02-13	Construction Deficiencies	Use approved construction type or materials.	E – Moderate Harm Potential
2025-02-13	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	E – Moderate Harm Potential
2025-02-13	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	E – Moderate Harm Potential
2025-02-13	Smoke Deficiencies	Properly select, install, inspect, or maintain portable fire extinguishes.	E – Moderate Harm Potential
2025-02-13	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2025-02-13	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2025-02-13	Miscellaneous Deficiencies	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	E – Moderate Harm Potential
2025-02-13	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	E – Moderate Harm Potential
2025-02-13	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure that testing and maintenance of electrical equipment is performed.	E – Moderate Harm Potential
2025-02-13	Miscellaneous Deficiencies	Have restrictions on the use of portable space heaters.	D – Moderate Harm Potential
2023-10-04	Construction Deficiencies	Use approved construction type or materials.	E – Moderate Harm Potential
2023-10-04	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	E – Moderate Harm Potential
2023-10-04	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	E – Moderate Harm Potential
2023-10-04	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2023-10-04	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	E – Moderate Harm Potential
2023-10-04	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2023-10-04	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2023-10-04	Smoke Deficiencies	Install smoke barrier doors that can resist smoke for at least 20 minutes.	E – Moderate Harm Potential
2023-10-04	Miscellaneous Deficiencies	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	E – Moderate Harm Potential
2023-10-04	Gas, Vacuum, and Electrical Systems Deficiencies	Meet requirements for the installation and maintenance of electrical systems.	E – Moderate Harm Potential
2023-10-04	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	E – Moderate Harm Potential
2023-10-04	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure that testing and maintenance of electrical equipment is performed.	E – Moderate Harm Potential
2023-10-04	Gas, Vacuum, and Electrical Systems Deficiencies	Have proper medical gas storage and administration areas.	E – Moderate Harm Potential
2023-10-04	Emergency Preparedness Deficiencies	Address patient/client population and determine types of services needed.	C – Minimal Harm Potential
2023-10-04	Emergency Preparedness Deficiencies	Conduct testing and exercise requirements.	C – Minimal Harm Potential
2021-09-22	Construction Deficiencies	Use approved construction type or materials.	E – Moderate Harm Potential
2021-09-22	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2021-09-22	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	E – Moderate Harm Potential
2021-09-22	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	E – Moderate Harm Potential
2021-09-22	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure that testing and maintenance of electrical equipment is performed.	E – Moderate Harm Potential

Total Penalties & Fines

$10,868

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2025-02-07	Fine	$10,868	-

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3-Year Complete Report ($19)

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