Below 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 Maple City Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Two residents in an LTC facility experienced deficiencies in care. One resident with a hand contracture did not receive necessary therapy or a care plan, leading to pressure ulcers. Another resident, post-surgery for an abscess, did not have a timely follow-up due to a rescheduled appointment and lack of wound care consultation. These failures resulted in harm and highlight issues in care coordination and communication.
A resident with left hemiparesis fell and sustained a brain bleed after the facility removed their side rails without proper assessment, despite the resident using them for mobility. The facility's blanket policy against side rails, intended to maintain a restraint-free environment, overlooked individual needs, leading to harm. Staff interviews revealed a lack of awareness and follow-up on the resident's mobility needs.
The facility did not complete baseline care plans within 48 hours of admission for all reviewed residents. Two residents lacked documented evidence of completed care plans, and 22 residents did not receive a summary of their care plans. Interviews revealed a lack of awareness and involvement in the care plan process, affecting residents with various diagnoses, including dementia and hypertension.
The facility failed to maintain a safe and clean environment, with roof leaks persisting for over a year and resident care equipment found dirty. Roof leaks were inadequately managed with temporary measures, and observations revealed missing ceiling tiles and water collection in trash cans. Oxygen concentrators and sit-to-stand lifts were found dirty, with unclear cleaning procedures contributing to the deficiency.
The facility failed to properly store and label medications, with expired drugs found in medication carts and rooms, and medications lacking expiration dates and resident identifiers. Despite monthly audits, these issues were missed, as confirmed by nursing staff and the DON.
A Recertification Survey identified deficiencies in the facility's main kitchen, including improper food storage and inadequate cleanliness. Food items were stored on the floor, and equipment and surfaces were soiled with food debris. The kitchen floors were dirty, and the dish room floor had missing grout, leading to stagnant water. Interviews confirmed the need for improved cleanliness and the absence of a permanent Food Service Director.
A resident with impaired vision and requiring assistance with personal hygiene was observed with debris under their fingernails over several days, including while eating. The facility's policy required daily nail cleaning, but there was no documentation of nail care being offered or refused. Staff interviews revealed inconsistencies in providing nail care and hand hygiene, particularly for residents eating in their rooms.
A resident with bilateral hearing loss did not receive necessary audiology services and hearing aids, despite a documented request and care plan intervention. The resident felt isolated due to hearing difficulties, and communication issues with family and staff contributed to the lack of follow-through on obtaining hearing aids.
A resident with a history of UTIs and an indwelling urinary catheter was observed with their catheter drainage bag and tubing on the floor without a barrier, and the bag was often full, causing urine backup. Despite care plans and orders for catheter care every shift, staff interviews revealed non-compliance with these protocols, increasing the risk of infection.
A resident with hemiplegia, malnutrition, and dysphagia did not receive appropriate tube feeding management. The facility failed to monitor the resident's nutritional intake, and there was confusion regarding physician orders for tube feeding during meals. Observations showed the resident was often disconnected from the feeding tube without a physician's order, and water flushes were administered incorrectly. The nutritional supplement Juven was frequently unavailable, and the medical team was not informed. Interviews with staff revealed a lack of communication and adherence to orders.
A resident with COPD, sleep apnea, and pneumonia was observed using oxygen via a nasal cannula without a physician's order, contrary to facility policy. Staff interviews revealed an oversight in obtaining the necessary order and documenting oxygen use, despite the resident's continuous need for oxygen since hospital readmission.
The facility failed to maintain an effective pest control program, resulting in the presence of small brown flies in the kitchen. Despite a policy for monitoring pest issues, maintenance logs showed no concerns, and staff were unaware of the problem. Observations noted flies in the dry storage room, and interviews revealed a lack of cleanliness and communication regarding pest control.
A survey revealed that a facility failed to provide necessary Medicare notices to several residents. The facility did not issue the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents who remained for custodial care and did not provide the Notice of Medicare Non-Coverage (NOMNC) to four residents at least two days before their Medicare services ended. Miscommunication among staff led to this oversight.
The facility did not post daily nurse staffing information as required, with observations showing outdated postings and missing information. Scheduler #1, responsible for this task, was on vacation, and no alternative arrangements were made. The Assistant Director of Nursing was unaware of the process, and the DON stated they were responsible for posting when Scheduler #1 was unavailable, but this was not done.
The facility failed to ensure an adequate number of CPR-certified personnel were available at all times, as evidenced by expired certifications and lack of tracking. Interviews revealed a lack of communication and oversight regarding the maintenance of CPR certifications, leading to the deficiency.
Deficiencies in Resident Care and Follow-Up
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for two residents, resulting in harm. Resident #71, who had a contracture of the left hand, did not have a care plan in place that included measurable goals, interventions, or monitoring. This oversight led to the development of multiple pressure ulcers and a decrease in range of motion. Despite the facility's policy on contracture management, there was no evidence of occupational therapy services or a splint being provided since September 2023. Observations and interviews revealed that Resident #71's contracture was not addressed, and the resident had been requesting therapy for two months without receiving it. Resident #59 was readmitted to the facility following surgical treatment for an abscess and did not receive a timely follow-up evaluation as ordered. The resident had a surgical incision on the right buttock, and the care plan included wound treatment and a post-operative appointment with a general surgeon. However, the appointment was rescheduled due to transportation issues, and the resident was not seen by a Wound Care Consultant. Interviews indicated that the rescheduling of the appointment was not communicated effectively, and the resident's wound was not evaluated by the surgeon as initially planned. The deficiencies in care for both residents highlight a lack of adherence to professional standards and facility policies. Resident #71's lack of a care plan and therapy interventions for the contracture resulted in pressure ulcers, while Resident #59's delayed surgical follow-up and lack of wound care consultation posed a risk of infection. These failures in care coordination and communication contributed to the harm experienced by the residents.
Failure to Accommodate Resident Needs Leads to Injury
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident #31, who had a history of stroke with left hemiparesis, chronic pain, and depression. The resident was cognitively intact and required substantial to maximum assistance for bed mobility. Despite these needs, the facility removed the side rails from the resident's bed, which the resident had been using to aid in mobility and prevent falls. This removal was done without an appropriate assessment, leading to the resident falling out of bed and sustaining a brain bleed. The facility's policy on side rails, last reviewed in January 2024, stated that side rails could be used to assist with mobility and transfers if they were not considered a restraint. However, the facility removed all side rails to maintain a restraint-free environment, without assessing individual resident needs. Interviews with staff, including CNAs and the Director of Nursing, revealed a lack of awareness and assessment regarding the necessity of side rails for Resident #31. The Occupational Therapist noted that the resident would benefit from side rails due to their condition, but this was not documented due to the facility's blanket policy against side rails. The incident was further compounded by the lack of follow-up after the resident's fall. Although a therapy evaluation was recommended, there was no evidence that it was completed. The Director of Nursing and other staff members were unaware of any assessments or alternative solutions being considered for the resident's mobility needs. The facility's failure to conduct a proper assessment and provide necessary accommodations resulted in actual harm to the resident, as evidenced by the fall and subsequent injury.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for all 24 residents reviewed during the recertification survey. Specifically, for two residents, there was no documented evidence that a baseline care plan was completed within the required timeframe. Additionally, for 22 residents, the facility could not provide evidence that a summary of the baseline care plan was provided to the residents or their representatives. This deficiency was identified through interviews and record reviews conducted during the survey. The facility's policy, dated January 2024, required that a baseline care plan be developed within 48 hours of admission and that a summary be provided to the resident or their representative. However, interviews with the Social Worker, Administrator, and Director of Nursing revealed a lack of awareness and involvement in the baseline care plan process. The Administrator noted that some data might have been in a previous electronic health record system, but no baseline care plans were found for the identified residents. This oversight affected residents with various diagnoses, including dementia, depression, hypertension, and other conditions, some of whom had severely impaired cognition.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies observed during the survey. Roof leaks were a significant issue, with the Environmental Services Director acknowledging that the roof had been leaking above the second-floor day room for over a year. Despite attempts to control the leaks with drainage tarps and cans, the problem persisted, and corporate responses indicated a lack of urgency in addressing the issue permanently. Observations revealed missing ceiling tiles and drainage tarps installed in the suspended ceiling, with water being collected in trash cans, indicating ongoing water intrusion problems. Additionally, resident care equipment was found to be dirty, compromising the safety and comfort of the residents. Oxygen concentrators in use in two resident rooms on the first floor were observed to have liquid spills, dust, and debris, with one resident stating that they had to clean the machine themselves as staff did not do so. Furthermore, sit-to-stand lifts on the second floor were found with rusty and debris-covered footrests, and the Environmental Services Director admitted that maintenance staff had missed cleaning them during monthly inspections. The Administrator acknowledged that there was a policy for cleaning oxygen concentrators, but the procedure was unclear, contributing to the deficiency.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals in accordance with State and Federal Laws during a Recertification Survey. Observations revealed that medication carts on Unit One Hall A and Unit Two Hall A contained expired medications, such as fish oil, Vitamin C, and Vitamin D3, as well as medications without expiration dates, including cetirizine hydrochloride and Lantus insulin. Additionally, the Unit Two medication room housed expired medications, including bisacodyl, fish oil, and Vitamin C, along with expired bisacodyl suppositories and influenza vaccines in the medication refrigerator. These deficiencies were identified during observations and interviews with nursing staff, who acknowledged that expired medications should not be stored and should have been identified during routine audits. Further observations on Unit One Hall A revealed a bottle of artificial tears eye drops without resident identifiers or expiration dates, and insulin vials without open or expiration dates. The Director of Nursing confirmed that resident-specific medications should be labeled with identifiers, and insulin and eye drops should have open and expiration dates. Despite monthly audits intended to check for expired medications and proper labeling, these deficiencies were overlooked, indicating a lapse in the facility's medication management practices.
Deficiencies in Kitchen Cleanliness and Food Storage
Penalty
Summary
During a Recertification Survey, the facility's main kitchen was found to have several deficiencies in food storage, preparation, and cleanliness, which did not meet professional standards for food service safety. Observations revealed that several food items, including juice containers, butter, soda, and milk crates, were stored directly on the floor in the walk-in cooler, and bags of vegetables and zucchini slices were on the floor in the walk-in freezer. The upright reach-in cooler was heavily soiled with food debris, and there were food crumbs in the base of the stainless plate warmer unit and in drawers containing large utensils. Additionally, a #6 scooper was found with dried food debris on it. Further observations noted that the kitchen floors under various equipment were dirty with food spillage, debris, and grime, and a soiled rag was stuffed into a drain line under the preparation sink. The dish room floor was missing grout, leading to stagnant water with food debris in the grooves. Interviews with the Acting Food Service Director/Registered Dietician and the Administrator confirmed the need for improved cleanliness and acknowledged ongoing issues with missing grout and the absence of a permanent Food Service Director. The facility's sanitization policy, dated January 2024, was not adhered to, as equipment and surfaces were not kept clean or in good repair.
Deficiency in Resident Nail Care and Hygiene
Penalty
Summary
During a Recertification Survey and complaint investigation, it was found that a resident with diagnoses including muscle weakness, depression, and arthritis, who was legally blind and required moderate assistance with personal hygiene, did not receive adequate nail care. Over several days, the resident was observed with dark debris underneath their fingernails, including while eating meals. The facility's policy required daily cleaning and regular trimming of nails, but there was no documented evidence that the resident was offered or refused nail care. Interviews with staff revealed that nail care was not consistently provided, and hand hygiene was not assisted prior to meals, particularly for residents eating in their rooms. The resident's care plan indicated a need for moderate assistance with personal hygiene and maximal assistance with bathing, but it did not address nail care refusals. Staff interviews highlighted a lack of documentation and follow-through on nail care, with one CNA admitting to not assisting the resident with handwashing due to being rushed. The LPN Manager and DON acknowledged that nail care should be addressed even outside of designated shower days, but this was not consistently practiced. The deficiency was identified under 10 NYCRR 415.12(a)(3).
Failure to Provide Hearing Services to Resident
Penalty
Summary
The facility failed to ensure that a resident, who was hard of hearing, received the necessary treatment and assistive devices to maintain their hearing. The resident, who had diagnoses including diabetes, depression, and bilateral hearing loss, was cognitively intact and expressed a desire to obtain hearing aids. Despite a documented request for an audiology evaluation, the facility did not arrange for this service. The resident reported feeling isolated due to their inability to hear and participate in activities, and although they were told the facility would assist in obtaining hearing aids, this did not occur. The resident's care plan included a referral to audiology for a hearing consult, but this was not followed through. Previous care plan meetings indicated that the resident's family did not want them to have hearing aids, and there was a history of lost hearing aids. Medical Records Staff attempted to arrange an audiology appointment but faced communication barriers with the resident and resistance from the family regarding payment for new hearing aids. The facility's administration was unaware of the resident's request for hearing aids until the survey, highlighting a breakdown in communication and follow-through on the resident's care plan.
Failure to Prevent Urinary Tract Infections in Resident with Catheter
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. Resident #25, who had a history of urinary tract infections and was cognitively intact, was observed multiple times with their urinary catheter drainage bag, catheter drainage port, and catheter tubing lying directly on the floor without a barrier. Additionally, the drainage bag was found completely full of urine, causing a backup of urine in the tubing. These observations were made despite the resident's care plan and physician's orders specifying catheter care every shift and monitoring for signs and symptoms of a urinary tract infection. Interviews with facility staff revealed a lack of adherence to the care plan and physician's orders. A Certified Nursing Assistant admitted that the drainage bag was frequently found on the floor and that the Kardex did not include instructions to keep it off the floor. A Licensed Practical Nurse confirmed that the drainage bag should never be on the floor or completely full, as this could lead to a urinary tract infection. The Director of Nursing acknowledged that documentation not signed off as completed could indicate that care was not provided, and emphasized the importance of emptying the drainage bag every shift and keeping it off the floor to prevent infections.
Inadequate Management of Tube Feeding for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a feeding tube, leading to potential complications. The resident, who had diagnoses including hemiplegia, protein-calorie malnutrition, and dysphagia, was cognitively intact and required tube feeding due to their inability to consume food and drink by mouth. The facility did not monitor the resident's total daily intake of tube feedings to ensure their nutritional needs were met, and there was a lack of clarity in the physician's orders regarding the administration of tube feedings during meals. Additionally, free water flushes and nutritional supplements were not administered as ordered by the physician. Observations revealed that the resident was often disconnected from their tube feeding during meal times without a physician's order to do so. The tube feeding pump settings did not match the physician's orders, and the water flushes were administered incorrectly. The resident's Medication Administration Records showed discrepancies in the administration of tube feedings and water flushes, and the nutritional supplement Juven was not consistently provided, with reasons documented as not available, not in stock, or not received from the pharmacy. There was no documentation of the total volume of tube feeding actually administered each day, and the medical team was not notified about the unavailability of the nutritional supplement. Interviews with facility staff, including nurses, a dietician, a physician, and the Director of Nursing, highlighted a lack of communication and adherence to physician orders. The staff were unaware of the need for a physician's order to stop tube feedings during meals, and there was no documented evidence that the medical team had been informed about the issues with the nutritional supplement. The facility's failure to ensure the resident received the tube feeding as ordered and to notify the medical team about the unavailability of the supplement contributed to the deficiency.
Failure to Ensure Physician's Order for Oxygen Use
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, as evidenced by the lack of a physician's order for oxygen use via a nasal cannula. Resident #85, who had diagnoses including chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and pneumonia, was observed wearing oxygen without a corresponding physician's order. The facility's policy required verification and review of a physician's order for oxygen administration, which was not adhered to in this case. The resident's comprehensive care plan indicated the need for oxygen per physician's orders, but no such order was found in the current physician's orders. Interviews with facility staff, including Licensed Practical Nurses and the Director of Nursing, revealed that there was an oversight in obtaining a physician's order for the resident's oxygen use. The resident had been on oxygen since being readmitted from the hospital, but this was not documented in the Medication Administration and Treatment Administration Records. Staff acknowledged the requirement for a physician's order for oxygen use and the need for documentation of oxygen settings per shift, which was not done for this resident. The Director of Nursing and Physician #1 confirmed the necessity of a physician's order for oxygen use, highlighting a lapse in the facility's adherence to its own policies and procedures.
Ineffective Pest Control Program in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of small brown flies and fruit flies in the kitchen area during a recertification survey and complaint investigation. The facility's pest control policy, dated January 2024, outlined procedures for monitoring and addressing pest issues, including maintaining a complaint log and conducting weekly environmental rounds. However, a review of maintenance logs from the past three months revealed no pest control concerns were noted by staff, despite ongoing issues with drain flies documented in pest control vendor treatment records. Observations during the survey noted approximately 20 small brown flies in the dry storage room of the main kitchen on multiple occasions. Interviews with facility staff, including the Acting Food Service Director/Registered Dietician and the Environmental Services Director, indicated a lack of awareness regarding the pest issue, with no documentation of flies in maintenance logs. The Acting Food Service Director also acknowledged that the kitchen was lacking in cleanliness and required more frequent deep cleaning. The facility Administrator was also unaware of any pest control concerns, highlighting a breakdown in communication and monitoring of pest control measures.
Failure to Provide Required Medicare Notices
Penalty
Summary
During a recertification survey conducted from August 18 to August 23, 2024, it was found that the facility failed to provide necessary Medicare notices to six out of seven residents reviewed. Specifically, the facility did not issue the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents who remained in the facility for custodial care after their Medicare Part A services ended. Additionally, the Notice of Medicare Non-Coverage (NOMNC) was not provided to four residents or their representatives at least two calendar days before the termination of their Medicare-covered services, as required by CMS guidelines. Interviews with facility staff revealed that the responsibility for issuing these notices was misunderstood. The Director of Admissions indicated that the therapy department was responsible for completing the NOMNC, while the Director of Rehabilitation was supposed to issue both the NOMNC and SNF ABN when applicable. However, there was an oversight, as the Director of Rehabilitation believed only the NOMNC was necessary. This misunderstanding led to the failure to inform residents of their appeal rights and potential financial liability for services not covered by Medicare.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily and accurately, as required by regulations. During a Recertification Survey conducted from August 18, 2024, to August 23, 2024, it was observed that the nurse staffing information was not visibly posted on August 18, 2024, and the information posted on August 20, 21, and 22, 2024, was outdated, showing the date of August 19, 2024. Interviews revealed that Scheduler #1, who was responsible for printing and posting the daily nurse staffing information, was on vacation, and no alternative arrangements were made to fulfill this responsibility. The Assistant Director of Nursing was unaware of the process for posting the daily staffing information, and the Director of Nursing stated that they were responsible for posting the information when Scheduler #1 was unavailable, with nursing supervisors responsible for off-shift postings. However, this process was not followed, leading to the deficiency.
Deficiency in Maintaining CPR-Certified Staff
Penalty
Summary
The facility failed to ensure that there were an adequate number of personnel certified in cardiopulmonary resuscitation (CPR) available to provide basic life support at all times. Specifically, the facility did not maintain an updated list of staff who were currently certified in CPR and could not provide evidence that a CPR-certified staff member was present in the facility during all shifts. This deficiency was evidenced by the review of the facility's list of licensed nursing staff, which revealed that 5 out of 32 active nurses were not currently certified in CPR. Additionally, timecard reviews indicated that no CPR-certified nurse or staff member was present during 7 out of 14 night shifts within the reviewed period. Interviews with various staff members, including the Director of Human Resources, the Assistant Director of Nursing, and several nurses, revealed a lack of communication and oversight regarding the maintenance of CPR certifications. The Nurse Educator, who was responsible for tracking CPR certifications, had not kept an updated list, and Human Resources did not collect this information during the hiring process. Several nurses reported that their CPR certifications had expired and that they had informed the relevant authorities, but no action was taken to renew their certifications. The current Administrator and Director of Nursing were unaware that CPR certifications were not being tracked or maintained, leading to the deficiency in ensuring CPR-certified staff were available at all times.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 2 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hornell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elderwood At Hornell | 2.3 mi | ★★★★★ | 0 | 0 |
| Steuben Center For Rehabilitation And Healthcare | 17.5 mi | ★★★★★ | 2 | 0 |
| Ira Davenport Memorial Hospital Snf/hrf | 20.1 mi | ★★★★★ | 0 | 0 |
| Highland Park Rehabilitation And Nursing Center | 20.3 mi | ★★★★★ | 0 | 0 |
| Wellsville Manor Care Center | 20.4 mi | ★★★★★ | 0 | 0 |
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