Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Absolut Ctr For Nursing & Rehab Endicott L L C during CMS and state inspections, most recent first.
Failure to Timely Report Alleged Abuse: A CNA reported witnessing another CNA use rough hands-on care with a resident, including holding the resident’s wrists, forcing the resident’s hands into the resident’s face, and bending the resident’s fingers backward while the resident yelled out. The resident had dementia, psychotic disorder, and severely impaired cognition. The allegation was not reported immediately, and another CNA who heard about it also did not report it right away; the accused aide remained working until the report reached the DON and Administrator.
The facility failed to provide a safe, clean, and comfortable environment, with unclean conditions in resident areas and inadequate maintenance of equipment. Staff shortages and poor communication contributed to these issues, and the facility also experienced a failure to maintain comfortable air temperatures, causing discomfort for residents and staff.
A resident in an LTC facility consistently received their meal tray significantly later than their roommate, causing discomfort and frustration. Meals were delivered on two separate carts at different times, leading to a delay of at least 30 minutes. Staff interviews revealed a lack of coordination in serving meals to roommates simultaneously, which did not align with the facility's policy to treat residents with dignity.
A resident requiring assistance with daily living activities was not dressed or shaved according to their care plan, despite being cognitively intact and able to express their needs. Staff interviews revealed a lack of adherence to the resident's care plan, impacting the resident's dignity.
Two residents in an LTC facility did not receive care according to professional standards. One resident was given an incorrect insulin dose, deviating from the prescribed sliding scale, and the error was not documented accurately. Another resident's oxygen tubing and humidifier bottle were not changed as required, with outdated equipment potentially contributing to a respiratory infection. Staff interviews revealed lapses in adherence to facility policies for medication and oxygen management.
A facility failed to maintain effective infection control practices, as a social worker improperly wore an N95 mask over a surgical mask, compromising its seal, while entering a COVID-19 positive room. Additionally, a resident with open wounds lacked appropriate precaution signage, and staff did not use PPE during care. These lapses were against facility policies, increasing infection risk.
The facility failed to provide appropriate liability and appeal notices to two residents when Medicare Part A services ended. A resident with muscle weakness and another with Parkinson's disease did not receive timely Notice of Medicare Non-Coverage or Advanced Beneficiary Notices. The Business Office Manager did not ensure certified mail receipts were documented, and no options were discussed with the residents' representatives, leading to automatic transitions to private pay without informed consent.
The facility failed to provide food and drink at safe and appetizing temperatures, with two residents reporting cold and unflavorful meals. Staff interviews revealed that meal trays were often delivered late, and the kitchen equipment was not functioning properly, affecting food temperatures.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported immediately, and no later than 2 hours after it was made, for one resident. Certified Nurse Aide #3 stated they witnessed Certified Nurse Aide #4 during incontinence care holding the resident’s wrists firmly, banging the resident’s fists into the resident’s face, and bending the resident’s fingers backwards. The resident was heard yelling “ouch” and “stop” during the incident. Certified Nurse Aide #3 did not report the event that night, and Certified Nurse Aide #7 also did not report the allegation after being told about it. The resident involved had diagnoses including dementia and psychotic disorder, and the most recent MDS documented severely impaired cognition. The care plan noted behaviors of physical aggression and resistance to care, bowel and bladder incontinence, and interventions such as reapproaching as needed, avoiding overstimulation, providing care out of the room, and stopping interaction if the resident became agitated. The incident report documented that there were no injuries, no signs of pain, and no verbal complaints, and that the medical provider and family were notified. Facility interviews and records showed that the allegation was not reported to the Administrator and DON until 04/20/2026 at 3:41 PM, while the accused aide remained on duty until the report was made. Staff statements conflicted about what occurred and when the allegation was shared. Certified Nurse Aide #3 said they were afraid of retaliation and believed they could wait to report it to a unit manager who was not on duty until later, while Certified Nurse Aide #7 stated they told Certified Nurse Aide #3 to report it on Monday and acknowledged they should have reported it immediately. The facility’s investigation also documented that Certified Nurse Aide #4 was suspended after the report was made.
Facility Fails to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents across multiple units. Observations revealed unclean conditions in hallways, bathrooms, and resident rooms, with dried debris, stains, and dust balls present. The main kitchen and unit pantry areas were also found to be unclean, with issues such as a grease trap with debris and blocked exits. Additionally, resident equipment was not properly maintained, as evidenced by a wheelchair with ripped armrests held together with tape, posing potential safety and dignity concerns. Interviews with staff highlighted systemic issues in the facility's cleaning and maintenance processes. Housekeeping staff were frequently absent or reassigned, leading to inadequate cleaning of resident areas. Staff reported that the facility was short-staffed, and there were no housekeepers on the evening shift. Maintenance issues were also prevalent, with broken equipment and unaddressed repair requests. The facility's policies on cleaning and maintaining a homelike environment were not effectively implemented, contributing to the observed deficiencies. The facility also failed to maintain a comfortable air temperature, with reports of cold conditions over a weekend. Residents and staff reported discomfort, with some wearing coats indoors and using extra blankets. The facility's maintenance logs were incomplete, and there was a lack of communication regarding the status of the heating system. The Assistant Maintenance Director confirmed that the boilers were not running, but the reason for this was unclear, and no temperature monitoring was conducted during the incident.
Failure to Ensure Dignified Meal Service for Resident
Penalty
Summary
The facility failed to ensure a dignified existence for Resident #411, who was cognitively intact and had a regular consistency diet. The resident consistently received their meal tray significantly later than their roommate, causing discomfort and frustration. Observations and interviews revealed that meals were delivered on two separate carts at different times, with Resident #411's tray arriving on the second cart, leading to a delay of at least 30 minutes after their roommate had been served and completed their meal. This delay caused Resident #411 to eat quickly due to hunger, resulting in discomfort. Staff interviews indicated that meal trays were not consistently arranged by room, and there was a lack of coordination in serving meals to roommates simultaneously. The facility's policy required residents to be treated with dignity, but the arrangement of meal carts and the timing of meal delivery did not align with this policy. Staff acknowledged that it was not dignified for Resident #411 to watch their roommate eat while they waited for their meal, and there was a consensus that roommates should be served together to maintain dignity.
Failure to Provide Adequate Personal Hygiene and Dressing Assistance
Penalty
Summary
The facility failed to ensure that a resident, who was unable to carry out activities of daily living independently, received the necessary services to maintain grooming and personal hygiene. Specifically, the resident, who was cognitively intact and required partial to moderate assistance for dressing and personal hygiene, was observed on multiple occasions wearing a hospital gown with dried food on it and expressed a desire to be dressed in street clothes and shaved. Despite the resident's ability to communicate their needs, they were not dressed or shaved as per their care plan. Interviews with facility staff revealed that the resident's shower day was on Tuesdays, which included shaving, but the resident was not shaved during their last bed bath. Staff acknowledged that the resident did not refuse care and that they should have sought assistance from the Unit Manager to ensure the resident was shaved. The Director of Nursing stated that the resident's care plan did not document any preference for wearing a gown or not being shaved, and emphasized that such issues could affect the resident's dignity and self-worth.
Medication and Oxygen Therapy Deficiencies
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, Resident #3 was administered the wrong dose of rapid-acting insulin. The resident, who had diagnoses including chronic obstructive pulmonary disease, anxiety, and diabetes, was supposed to receive 8 units of insulin aspart for a blood sugar level of 228 milligrams/deciliter, according to the sliding scale ordered by the Nurse Practitioner. However, Licensed Practical Nurse #23 administered 10 units instead, which was a deviation from the prescribed order. This discrepancy was not documented accurately in the electronic medical record, and the Nurse Practitioner was not notified of the error. Resident #8, who had diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, and pneumonia, did not have their oxygen tubing or humidifier bottle changed regularly as required. The resident was on continuous oxygen therapy, and the medical order specified that the oxygen tubing and humidifier bottle should be changed weekly. However, during observations, it was found that the humidification canister was dated 9/2/2024, indicating it had not been changed for several weeks, and the oxygen delivery tubing was not dated. This oversight was not documented in the Medication and Treatment Administration Record, and the resident was diagnosed with acute pneumonia, which could have been exacerbated by the outdated equipment. Interviews with the nursing staff and the Director of Nursing revealed that there was a lack of adherence to the facility's policies and procedures regarding medication administration and oxygen therapy management. The staff acknowledged the errors in insulin administration and the failure to change the oxygen equipment as ordered. The Director of Nursing confirmed that these lapses could pose safety concerns for the residents, as incorrect insulin dosing could lead to hypoglycemia, and outdated oxygen equipment could contribute to respiratory infections.
Infection Control Deficiencies in PPE Usage and Precaution Signage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving a staff member and a resident. Social Worker #5 was observed entering a COVID-19 positive room wearing an N95 mask incorrectly, with a surgical mask placed between the N95 mask and their face, which compromised the mask's seal. This was contrary to the facility's COVID-19 Action Plan, which required N95 masks to be worn tightly against the face to prevent the transmission of germs. Despite receiving training on proper N95 mask usage during orientation, Social Worker #5 did not adhere to the guidelines, potentially increasing the risk of infection spread. Additionally, Resident #160, who had a skin abscess and pressure ulcers, was not provided with appropriate transmission-based precautions. The resident was on enhanced barrier precautions due to open wounds and an intravenous line, but there was no signage indicating these precautions at the entrance to their room. During an observation, two certified nurse aides were seen providing incontinence care to the resident without wearing gowns or gloves, which was against the facility's policy for residents on contact precautions. The lack of signage and personal protective equipment use increased the risk of infection transmission. Interviews with various staff members, including the Director of Nursing and the Infection Control Nurse, confirmed that the facility's policies required N95 masks to be worn correctly and signage to be posted for residents on isolation precautions. However, these protocols were not followed in the observed cases, indicating a lapse in the facility's infection control practices. The failure to adhere to established guidelines and ensure proper protective measures were in place contributed to the identified deficiencies.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide appropriate liability and appeal notices to Medicare beneficiaries for two residents, resulting in a deficiency. Resident #27, who had diagnoses including muscle weakness, diabetes mellitus type 2, and osteoporosis, was not given timely Notice of Medicare Non-Coverage when Medicare Part A services ended. The facility's Business Office Manager documented that the notice was issued over the phone and sent by certified mail, but there was no evidence of a certified mail receipt. Additionally, the Advanced Beneficiary Notice of Non-Coverage was not completed, and no options were discussed with the resident's representative. Similarly, Resident #141, who had diagnoses including Parkinson's disease, severe protein-calorie malnutrition, and encephalopathy, did not receive the required notices when Medicare Part A services ended. The Business Office Manager left a message for the resident's spouse and claimed to have sent the notice by certified mail, but again, there was no documented evidence of a certified mail receipt. The Advanced Beneficiary Notice of Non-Coverage was not completed, and no options were discussed with the resident's spouse. Interviews with the Business Office Manager revealed that the process for issuing notifications was not followed correctly, as they did not ensure the residents or their representatives were informed of their right to appeal or provided with all necessary options. Interviews with the residents' representatives confirmed they did not receive certified letters or explanations about the ability to appeal the Medicare non-coverage of services, leading to automatic transitions to private pay without their informed consent.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable, attractive, and at safe and appetizing temperatures during the recertification survey. Specifically, during lunch meals on two consecutive days, food was not served at the appropriate temperatures. Observations revealed that the fried chicken, yogurt, and cooked carrots served to Resident #18 were not within the required temperature range. Similarly, the broccoli, pineapple, cold water, and milk served to Resident #85 were also outside the acceptable temperature limits. Residents expressed dissatisfaction with the food, stating it was cold and lacked flavor. Interviews with staff revealed systemic issues contributing to the deficiency. Certified Nurse Aides reported that meal trays were often delivered late, and residents frequently complained about the food being cold and unappetizing. The Assistant Food Service Director acknowledged that the kitchen equipment, specifically the ovens, were old and not functioning properly, which affected the food temperatures. The maintenance team had attempted repairs, but the issues persisted, and both the Director of Maintenance and the Administrator were aware of the ongoing problems.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Endicott
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ideal Senior Living Center | 1.5 mi | ★★★★★ | 6 | 0 |
| Good Shepherd Village At Endwell | 3.2 mi | ★★★★★ | 6 | 0 |
| Vestal Park Rehabilitation And Nursing Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Willow Point Rehabilitation And Nursing Center | 4.5 mi | ★★★★★ | 0 | 0 |
| Susquehanna Nursing & Rehabilitation Center, L L C | 5.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.