Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Waters Of Syracuse Skilled Nursing Facility, The during CMS and state inspections, most recent first.
A resident with a UTI, CKD, DM2, PVD, CHF, and an indwelling catheter had missed antibiotic doses and later had a reported change in mentation noted by a psychologist. The record lacked documentation of a timely assessment after the change was reported, and the resident was ultimately hospitalized for sepsis for twenty days.
Improper Food Handling During Meal Service: During a dining observation, multiple employees served beverages and plates while touching the eating and drinking surfaces, and one employee’s fingers were observed touching pudding and mashed potatoes while serving food. The Administrator acknowledged that placing hands on the eating surface of plates was not proper, and no policy on proper food service techniques was provided before the end of the survey.
A resident with CHF, depression, Parkinson's disease, epilepsy, OA, and CKD did not receive an ordered bed enabler bar needed for self-transfers. He said he could not get out of bed to use the bathroom by himself without it, and the MD stated the facility's enabler bars did not fit his older bed, so a new bed was ordered but had not yet been placed in his room. The resident's MDS showed intact cognition and moderate assist for transfers, and the physician had ordered the enabler bar.
A resident with DM2, PVD, neuropathy, and intellectual disabilities had repeated blood glucose readings above 400 mg/dL while on sliding-scale insulin, but the physician was not notified timely. The resident’s care plan directed staff to report abnormal blood sugars promptly, and the DON stated the provider should have been notified when blood glucose was over 400 mg/dL.
Failure to Attempt GDR for Lorazepam: A resident with anxiety, depressive disorder, and altered mental status remained on Lorazepam 0.25 mg BID for anxiety despite pharmacy recommendations to reduce the dose to daily and no documented behaviors on monitoring reports. The FNP agreed with the dose reduction recommendation, but the order was not entered in the resident record, and the DON stated the change order should have been entered by the DON.
Failure to follow medication orders and document omissions. A resident with multiple chronic conditions, including CKD, DM2, HTN, CHF, depression, anxiety, and hyperthyroidism, had repeated doses of metoprolol given without required BP checks, and at times the medication was given even when recorded BP values were outside the ordered hold parameters. The resident also missed several ordered medications without documentation explaining why they were not administered. Interviews with an LPN, RN, and the DON confirmed that medications should not be given without required assessments and that omitted doses should be documented.
A resident with CHF and HTN who was receiving a diuretic had a physician order for weekly weights and notification for a 2-lb gain, but the record showed weights were not documented weekly. The DON stated the weights should have been charted weekly and that an electronic prompt had not been added to the order in the EHR.
A facility failed to ensure a time-sensitive eye drop bottle for a resident was dated when opened. Surveyors found the opened bottle on the med cart without an open date, and a QMA stated it should have been dated when opened. The facility’s current med storage policy addressed outdated drugs, but no policy for dating opened meds was provided.
Failure to maintain an effective pest control program was cited after a resident reported a long-standing fly problem in her room and bathroom. Surveyors observed multiple flies on the walls, and the resident’s family showed an E-Z trap behind the toilet that was heavily covered with dead flies. The MD and HS denied awareness of the issue, despite prior pest control treatment for insect activity and a facility policy requiring staff to report pest sightings or evidence of pests.
Two residents at a facility experienced falls due to inadequate implementation of fall prevention interventions. One resident, with a history of falls and high fall risk, suffered a brain hemorrhage after an unwitnessed fall, while another resident rolled out of bed due to the absence of planned interventions. Staff interviews revealed a lack of awareness and communication regarding necessary interventions.
The facility's kitchen was found to have multiple sanitation deficiencies, including unsealed and undated food items, expired foods, and dirty cooking utensils, affecting all 44 residents receiving meals. Observations included dirty freezer seals, improperly stored food, and unsanitary food handling practices. The facility's policies on food storage and equipment cleaning were not followed.
A resident with a history of bladder dysfunction and kidney failure was observed multiple times without a dignity cover on her urinary drainage bag, allowing urine to be visible. Despite a physician's order for the bag to be covered, the facility's policy did not specify this requirement, and a CNA confirmed that the bags should be covered.
The facility did not provide a SNF-ABN to two residents after their Medicare services ended, despite having remaining Medicare A days. The Business Office Manager confirmed the oversight, and the facility lacked a policy for ABN administration and documentation.
A facility failed to complete a timely PASARR for a resident with serious mental illness and/or intellectual disability. The initial PASARR Level 1 screening authorized a 60-day convalescence care, requiring re-screening by the 60th day if the resident remained in the facility. However, no new Level 1 screen was documented before the expiration date. The Social Service consultant noted that the Business Office Manager was instructed to initiate the process, but it was not completed as per the facility's policy.
The facility failed to initiate proper baseline care plans for two residents, one requiring dialysis and another at high risk for falls. Both residents' care plans lacked necessary goals and interventions, contrary to facility policy. This deficiency was confirmed through record reviews and staff interviews.
The facility failed to maintain comprehensive care plans for three residents, leading to deficiencies in their care. A resident with cerebral infarction and COPD lacked an active care plan for ADLs, while another with a Foley catheter had no plan for catheter care. Additionally, a resident receiving medication for hypothyroidism did not have a care plan for this condition. The MDS Coordinator confirmed the absence of necessary care plans, contrary to facility policy.
The facility failed to conduct timely care plan meetings for three residents, resulting in gaps in care planning. One resident had no documented meetings after April, another missed a quarterly meeting, and a third had a significant gap between meetings. The Corporate Social Service Director and Regional MDS Consultant confirmed these oversights.
A resident with a history of bladder dysfunction and urinary tract infections was observed with an indwelling urinary catheter without documented necessity. Despite being cognitively intact and frequently incontinent, the facility did not complete a structured toileting program evaluation. The Nurse Practitioner did not attempt alternative interventions before catheter placement, and the Director of Nursing could not provide documentation for a neurogenic bladder diagnosis.
A facility failed to ensure proper nutritional management for three residents, leading to deficiencies in care. A resident with significant weight loss did not have their supplement intake documented, while another experienced delayed implementation of dietician recommendations and was not included in a weight assessment program. Additionally, a resident with chronic kidney disease was served meals not aligned with their dietary restrictions. The facility's oversight in documentation and meal service contributed to these deficiencies.
The facility failed to properly store respiratory equipment for two residents, leading to deficiencies in care. A resident's C-PAP mask was found unbagged and on the floor, while another resident's nasal cannula tubing was improperly stored on the floor. Staff interviews confirmed the equipment should have been stored in respiratory bags, but the facility's policy lacked specific guidelines for storage.
A facility failed to monitor the effectiveness of pain medication for a resident with multiple diagnoses, including diabetes and polyneuropathy, who was prescribed Tramadol for pain management. Despite the care plan's requirement to monitor medication effectiveness, the MARs for several months lacked documentation. A nurse confirmed the oversight, and the facility's policy required documentation of medication effectiveness, which was not followed.
A facility failed to complete pre and post dialysis assessments for a resident with chronic kidney disease, missing several assessments over a period of time. The resident's care plan required monitoring for fluid volume changes, but the absence of these assessments indicates non-compliance with the care plan. A nurse confirmed the necessity of these assessments for communication with the dialysis center.
A resident with multiple diagnoses was prescribed a high dose of cholecalciferol, resulting in elevated vitamin D levels. Despite lab results indicating levels above the normal range, the nurse practitioner did not adjust the medication dosage. The facility's policy for monitoring lab results was not effectively followed, leading to a deficiency in ensuring the drug regimen was free from unnecessary drugs.
A resident with major depressive disorder and moderate cognitive impairment received Xanax beyond the 14-day limit for PRN psychotropic medications without proper documentation or physician evaluation. Facility staff were unaware of the time limits, and drug reviews were conducted every six months. The resident had multiple emergency room visits, and the emergency room physician prescribed Xanax for shortness of breath, but no progress note justified the extended use.
The facility failed to maintain the nutritive value and flavor of pureed diets for two residents. The Dietary Manager prepared pureed carrots without adding chicken base as per the instructions, which were taped inside a cabinet door. The omission was acknowledged during an interview, and the facility's policy on consistency-modified foods was provided.
The facility failed to ensure proper infection control practices for residents on Enhanced Barrier Precautions (EBP). A nurse administered medication to a resident with a PEG tube without wearing a gown, and two CNAs did not use appropriate PPE while providing care to residents on EBP. The facility's policy required gloves and gowns during high-contact activities, which was not followed.
Delayed Assessment After Change in Cognition
Penalty
Summary
The facility failed to timely assess a resident after a reported change in cognition, and the resident was not sent for further evaluation until after the change had been identified. Resident 31 had diagnoses including urinary tract infection, benign prostatic hyperplasia, obstructive and reflux uropathy, stage four chronic kidney disease, type two diabetes mellitus, peripheral vascular disease, and congestive heart failure. He had an indwelling urinary catheter, was dependent on staff for toileting, personal hygiene, showering, and all mobility and transfer needs, and had a quarterly MDS indicating intact cognition and no behaviors or rejection of care. Record review showed Resident 31 had a urinary tract infection and was ordered cephalexin, but two scheduled doses were not administered on 3/7/2026 and there was no documentation explaining why. The antibiotic was later changed to sulfamethoxazole-trimethoprim after culture results identified citrobacter previndii. On 3/12/2026, the ADON documented that the Social Services Director reported a psychologist had visited the resident and found his mentation to be off, and that the psychologist had notified the nurse responsible for the resident. The note stated the LPN said the resident had been assessed and a change from cognitive baseline was identified, but the resident’s record lacked documentation that any assessment had been completed after the psychologist reported the change in cognition. The resident later required hospitalization for sepsis and remained in the hospital for twenty days.
Improper Food Handling During Meal Service
Penalty
Summary
Food was not handled properly during a dining observation, as Employees 4, 11, and 16 served 14 cups and/or glasses of beverages and 6 plates of food while touching the eating and drinking surfaces of the cups, glasses, and plates. In addition, Employee 4 was observed with fingers touching pudding and mashed potatoes while serving food. During interview, the Administrator acknowledged that placing employee hands on the eating surface of plates of food was not a proper way to serve food. When asked for a policy regarding proper food service techniques, the Administrator did not provide one before the end of the survey.
Failure to Provide Ordered Bed Enabler Bar
Penalty
Summary
The facility failed to reasonably accommodate a resident who needed an enabler bar on his bed for self-transfers. Resident 32 stated during interview that he was unable to get out of bed to use the bathroom by himself because the enabler bar had not been installed. He also reported that he had been told on two occasions by the Maintenance Director that the bar had been ordered, but it still had not been placed on his bed. Resident 32 had diagnoses including chronic diastolic congestive heart failure, depression, Parkinson's disease, epilepsy, osteoarthritis, and chronic kidney disease. His MDS indicated intact cognition and that he required moderate assistance for all transfers. The care plan identified increased risk for pain and discomfort related to Parkinson's disease, decreased strength and mobility, and osteoarthritis. A physician's order dated 4/29/2026 directed that he have an enabler bar attached to his bed, and a side rail assessment indicated he was safely able to use one and had consented to it. The Maintenance Director stated the resident's older style bed did not allow the facility's enabler bars to attach correctly, so a new bed was ordered, but the resident was still waiting for a bed with an enabler bar.
Failure to Notify Physician of Repeated Critical Blood Glucose Readings
Penalty
Summary
The facility failed to ensure the physician was notified in a timely manner of multiple elevated blood glucose readings for one resident reviewed for unnecessary medications. Resident 36 had diagnoses including type 2 diabetes mellitus, peripheral vascular disease, neuropathy, and intellectual disabilities, and the quarterly MDS indicated the resident was cognitively intact and received insulin injections during the look-back period. The physician’s order for sliding-scale insulin directed staff to call the doctor when blood glucose was 351 to 400 mg/dL and above. Record review showed repeated blood glucose readings above 400 mg/dL without notification to the physician, including values of 404, 436, 406, 416, 404, 441, 402, 411, 435, 462, 421, 496, 407, 426, 425, and 448 mg/dL on multiple dates in February, March, and April 2026. The care plan identified the resident as at risk for unstable blood sugars and directed staff to administer insulin as ordered, document blood glucose readings and insulin administrations, and report abnormal blood glucose readings or insulin results promptly to the provider. The DON stated that when the resident had a blood sugar over 400 mg/dL, the provider should have been notified.
Failure to Attempt Gradual Dose Reduction for Lorazepam
Penalty
Summary
The facility failed to ensure a gradual dose reduction was attempted for psychotropic medication use for Resident 24, who had diagnoses including anxiety, depressive disorder, and altered mental status. The resident had an order for Lorazepam 0.25 mg by mouth twice daily for anxiety, which was discontinued and then reordered. Behavior monitoring orders were in place for tearful periods, isolation, anxiety, depression, and for observing side effects of psychotropic drugs, and the behavior monitoring reports showed no behaviors from December 14, 2025 through May 20, 2026. A pharmacy review dated 12/14/2025 recommended reducing Lorazepam from 0.25 mg twice daily to 0.25 mg daily, but there was no provider signature or date acknowledging receipt of the recommendation. A second pharmacy review dated 2/20/2026 again recommended reducing the dose to 0.25 mg daily, and the FNP agreed with the recommendation on 2/20/2026, but the order was not initiated in the resident's record. During interview, the DON stated the change order should have been entered by the DON.
Failure to Follow Medication Orders and Document Omitted Medications
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated competency in following medication orders for Resident 31. Resident 31 had diagnoses including urinary tract infection, benign prostatic hyperplasia, obstructive and reflux uropathy, stage four chronic kidney disease, type two diabetes mellitus, hyperthyroidism, major depressive disorder, anxiety disorder, peripheral vascular disease, hypertension, and congestive heart failure. The resident’s quarterly MDS indicated intact cognition, no rejection of care, and no behavioral concerns. Review of the February 2026 MAR showed metoprolol was administered on multiple dates without a blood pressure being assessed before administration, despite the order to hold the medication if systolic BP was below 110 or diastolic BP was below 80. The nursing staff involved included RN 5, LPN 6, QMA 8, LPN 9, and LPN 10. The same month, bupropion, cholecalciferol, and levothyroxine were not administered on the morning of 2/14/2026, and the record lacked documentation explaining why those medications were not given. Review of the March, April, and May 2026 MARs showed repeated administration of metoprolol without a blood pressure assessment before giving the medication, and in April the medication was also given on several dates when the recorded blood pressures indicated it should have been held. In March, alprazolam, furosemide, cephalexin, and apixaban were not administered on 3/7/2026 without documentation explaining the omission. Interviews with LPN 7, RN 5, and the DON confirmed that metoprolol should not have been given without a blood pressure reading and that omitted medications should have been documented. The DON also stated medication administration was part of new hire orientation and that staff who passed medications had their skills checked and signed off, and the skill checkoffs for the DON, RN 5, LPN 6, LPN 7, QMA 8, LPN 9, LPN 10, LPN 12, QMA 13, LPN 14, and QMA 15 were completed without concerns.
Failure to Follow Ordered Weekly Weight Monitoring
Penalty
Summary
The facility failed to follow a physician-ordered medication monitoring requirement for one resident with acute on chronic diastolic congestive heart failure and hypertension who was receiving a diuretic. A quarterly MDS dated 3/23/2026 indicated the resident was cognitively intact and on a diuretic. A physician order dated 4/10/2026 directed that weekly weights be obtained for congestive heart failure and that the physician be notified if there was a weekly weight gain of two pounds or more. Review of the resident’s weights for April and May 2026 showed weights were only documented for the weeks including 4/29/2026, 5/11/2026, and 5/13/2026. During interview, the DON stated the resident’s weight values should have been documented weekly in the medical record and that an electronic prompt to document the weight had not been added to the physician order in the electronic clinical record.
Undated Open Eye Drops
Penalty
Summary
The facility failed to ensure a time-sensitive medication was dated when opened for one resident on the Teal Unit. During inspection of the medication cart, surveyors found a bottle of eye drops for Resident 25 that had been opened but did not have an open date on the bottle. In an interview, QMA 3 stated the eye drops should have been dated when they were opened. The facility provided its current Medication Storage in the Facility policy, which stated that outdated drugs will be immediately withdrawn from stock, but it did not provide a policy for dating medications when opened.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program related to flies in one resident’s room. Resident 25 reported having a fly problem for about a year and stated staff were aware of the issue. During observation, a dozen flies were seen on the walls of the resident’s room and six flies were seen on the bathroom walls. The resident’s family member stated she had purchased E-Z traps eight or nine months earlier to address drain flies, and the trap found behind the toilet was about 80% covered with dead flies. During a tour with the Maintenance Director and Housekeeping Supervisor, both denied knowledge of any reported fly issue in the room or bathroom and denied knowing about the E-Z trap behind the toilet. The Housekeeping Supervisor stated daily bathroom cleaning should have revealed the trap, and the Maintenance Director stated he toured the building daily and had been in the room within the last six months without knowing there had ever been a fly problem. Pest control invoices showed the room had been inspected and treated twice for insect activity, and the facility policy required an effective pest control program and notification to the Administrator when pests or evidence of pests were found.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement interventions to reduce the risk of falls for two residents, resulting in a fall that required hospitalization for one of them. Resident 247, who was admitted with a history of falls and a high risk for future falls, did not have any interventions in place to prevent falls despite being identified as high risk. The resident experienced an unwitnessed fall, leading to a brain hemorrhage and subsequent hospitalization. Observations revealed that the resident continued to walk unassisted without any assistive devices or reminders to use the call light, even after returning from the hospital. Resident 27, who was severely cognitively impaired and required extensive assistance, also experienced a fall due to rolling out of bed. Although a new intervention was planned to place the bed in the lowest position with a fall mat beside it, this intervention was not consistently implemented. Observations showed that the resident's bed was not in the lowest position, and the fall mat was not in place during multiple checks. Interviews with staff indicated a lack of awareness and communication regarding the interventions for both residents. The Director of Nursing acknowledged that new interventions should be communicated through the electronic record and during shift change huddles, but there was a failure to ensure these interventions were consistently applied. The facility's policy required a site investigation and new care plan interventions for each fall, but this was not adequately followed for the residents involved.
Sanitation Deficiencies in Kitchen Affecting Resident Meals
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect all 44 residents receiving meals. During an initial tour, several issues were observed, including unsealed and undated food items in the freezer and cooler, expired foods in use, and dirty cooking utensils and appliances. Specific observations included dirty seals and food debris in the reach-in freezer, improperly sealed sausage links and Salisbury steak, and opened and undated food items such as dill pickles and chicken gravy. Additionally, personal items were found in the walk-in cooler, and the kitchen floor was stained and littered with food debris. Further inspections revealed additional unsanitary conditions, such as a metal spoon and dish rag found under food prep areas, and a cook resting plates against his uniform during food plating. A revisit to the kitchen showed a dirty microwave plate, stained drinking glasses, and improperly cleaned or damaged cooking utensils, including a greasy metal pan and a spatula with burnt areas. The facility's policies on food storage, labeling, and equipment cleaning were not adhered to, as evidenced by the lack of sanitizing solution in the cleaning bucket and the presence of undated and improperly stored food items.
Failure to Provide Dignity Cover for Urinary Catheter
Penalty
Summary
The facility failed to provide a dignity cover for a urinary indwelling catheter for Resident 34, who was observed multiple times without a dignity cover on her urinary drainage bag. On several occasions, the urinary drainage bag was visible and not covered, allowing urine to be seen through the clear side of the bag. This was observed while the resident was in her recliner, during transport to the therapy room, and while in the therapy room. Additionally, the drainage bag was noted to be leaking on the floor during one observation. Resident 34 has a history of neuromuscular dysfunction of the bladder, kidney failure, and urinary tract infections, and is cognitively intact. The facility's policy did not specify the need for dignity covers for indwelling urinary catheters, despite a physician's order indicating that the catheter drainage bag should be covered. A CNA confirmed that Foley catheter drainage bags should be covered, highlighting a discrepancy between staff understanding and facility policy.
Failure to Provide SNF-ABN to Residents Post-Medicare Discharge
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) to two residents who were discharged from Medicare services but remained in the facility. Resident 9 was given a Notice of Medicare Non-Coverage (NOMNC) indicating that Medicare coverage would end on August 28, 2024, despite having 34 Medicare A days remaining. Similarly, Resident G received a NOMNC stating that Medicare coverage would end on June 6, 2024, with 57 Medicare A days left. The Business Office Manager confirmed that both residents were not issued an SNF-ABN after their Medicare A services ended. Additionally, the facility lacked a policy for the administration and documentation of ABN notices, as confirmed by the Executive Director.
Failure to Complete Timely PASARR for Resident
Penalty
Summary
The facility failed to ensure a timely completion of a PASARR (Pre-Admission Screening and Resident Review) for a resident, identified as Resident B. Resident B's medical history included fractured ribs, cancer, end-stage renal disease, bipolar disorder, and malnutrition. A PASARR Level 1 screening was initially completed on June 16, 2024, which identified the resident as having a serious mental illness and/or intellectual disability, placing them in the Convalescence category with a 60-day convalescence care approval. The screening indicated that a re-screening was required by or before the 60th day if the resident was expected to remain in the nursing facility beyond the authorized timeframe. However, the facility's records lacked documentation of a new Level 1 screen being completed before the expiration date of September 14, 2024. During an interview, the Social Service consultant acknowledged that another Level of Care PASARR form should have been completed in September and indicated that the Business Office Manager was instructed to initiate the process. The facility's policy, provided by the Corporate MDS consultant, outlined that the Business Office Manager should initiate a new Level 1 and Level of Care 7-14 days prior to the expiration date, but this was not adhered to in Resident B's case.
Failure to Initiate Baseline Care Plans for Residents
Penalty
Summary
The facility failed to ensure baseline care plans were properly initiated for two residents, leading to deficiencies in care planning. Resident B, who had diagnoses including fractured ribs, cancer, end-stage renal disease, bipolar disorder, repeated falls, and malnutrition, was admitted and required dialysis. However, the baseline care plan for Resident B, dated the same day as the admission, lacked specific goals, interventions, and special needs to address the resident's conditions. This omission was confirmed during an interview with the MDS coordinator, who acknowledged that the care plan summary should have included these elements. Similarly, Resident 247, who was admitted with conditions such as subarachnoid hemorrhage, cardiomegaly, falls, insomnia, and polyneuropathy, was identified as being at high risk for falls. Despite this, the baseline care plan for Resident 247, created two days after admission, did not include goals or interventions for fall prevention. The comprehensive care plan addressing falls was not completed until much later, while the resident was hospitalized. The facility's policy required the admitting nurse to initiate a baseline care plan to identify potential problems and establish appropriate goals and interventions, which was not adhered to in these cases.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to maintain comprehensive care plans for three residents, leading to deficiencies in their care. Resident 18, who had diagnoses including cerebral infarction, spinal stenosis, and COPD, was observed with facial hair stubble, indicating a lack of assistance with personal hygiene. The care plan for activities of daily living (ADLs) for this resident was not active, as it had been resolved prematurely. The MDS Coordinator confirmed that Resident 18 should have had an active care plan addressing his ADL needs. Resident 20, who had a Foley catheter due to conditions such as chronic kidney disease and congestive heart failure, did not have an active care plan for catheter care. The care plan had been resolved earlier, leaving the resident without a documented plan for this critical aspect of care. Similarly, Resident 32, diagnosed with conditions including underweight and osteoarthritis, was receiving medication for hypothyroidism, yet lacked a care plan for this condition. The MDS Coordinator acknowledged the absence of a care plan for hypothyroidism, which should have been in place. The facility's policy requires comprehensive care plans to be developed and maintained, but these were not adhered to for the residents in question.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure timely care plan meetings for three residents, leading to deficiencies in care planning. Resident 27, diagnosed with arthritis, hypertension, obstructive and reflux uropathy, and glaucoma, had a care plan meeting in April 2024, but no subsequent meetings were documented, despite the requirement for additional meetings. The Corporate Social Service Director confirmed that two additional meetings should have occurred but did not. Resident 38, with a history of femur fracture, hemiplegia, hemiparesis, muscle contracture, malnutrition, stroke, depression, and dysphagia, had a care plan meeting in July 2024, but no further meetings were documented. The resident's POA was unaware of the need for quarterly meetings, and the Corporate Social Service Director acknowledged that a meeting should have been held in October. Resident 30, who reported never attending a care plan conference, had a gap in documented care plan meetings between November 2023 and December 2024, which the Regional MDS Consultant confirmed should not have occurred.
Failure to Justify Indwelling Catheter Use for Incontinent Resident
Penalty
Summary
The facility failed to ensure that a resident, who was incontinent, remained free from an indwelling urinary catheter. During an observation, the resident was seen with urinary drainage tubing over her thigh and a drainage bag attached to her wheelchair. The resident had a history of neuromuscular dysfunction of the bladder, kidney failure, and urinary tract infections. Despite being cognitively intact and frequently incontinent of bladder, the resident was noted to have an indwelling urinary catheter without a documented diagnosis justifying its necessity. The facility's policy requires that residents not be catheterized unless clinically necessary, and that appropriate treatment and services be provided to prevent urinary tract infections and restore continence. The resident's medical records indicated a Foley catheter was placed due to constant urine leakage, but there was no supporting documentation for a neurogenic bladder diagnosis. A Bowel and Bladder Incontinence Screener suggested further evaluation for a structured toileting program, which was not completed. Interviews revealed that the Nurse Practitioner did not attempt alternative interventions such as medication, bladder scans, or a toileting program before catheter placement. Additionally, the Director of Nursing claimed a full medical examination for neurogenic bladder was conducted, but no documentation was available to support this claim.
Nutritional Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper nutritional management for three residents, leading to deficiencies in their care. Resident 1, who had a history of diabetes, anxiety, kidney failure, and polyneuropathy, experienced significant weight loss. Despite a physician's order for nutritional supplements, the facility did not consistently document the percentage of supplements consumed, and the Director of Nursing acknowledged the oversight in the electronic charting system. This lack of documentation hindered the ability to monitor the resident's nutritional intake effectively. Resident 27, diagnosed with arthritis, hypertension, obstructive and reflux uropathy, and glaucoma, also experienced significant weight loss. The facility did not promptly implement the dietician's recommendations for nutritional supplements, resulting in a delay of nine days. Furthermore, the facility failed to document the consumption of these supplements, which was crucial for assessing their effectiveness. The resident was not included in the Skin-Weight-Assessment-Team program, despite meeting the criteria for significant weight loss. Resident 20, who had chronic kidney disease, mild protein-calorie malnutrition, diabetes mellitus type 2, and gastroparesis, was not served the appropriate diet for his condition. The facility provided meals that did not align with the dietary restrictions for a renal diet, such as serving mashed potatoes instead of rice and providing larger portions of peach cobbler. The Dietary Manager admitted to not realizing the main menu diet differed from the renal diet, leading to inappropriate meal service for the resident.
Improper Storage of Respiratory Equipment for Two Residents
Penalty
Summary
The facility failed to properly store oxygen therapy and C-PAP equipment for two residents, leading to deficiencies in respiratory care. For Resident 18, observations revealed that the C-PAP mask was repeatedly found unbagged on top of a personal refrigerator and even on the floor. Despite a physician's order for the resident to use the C-PAP at bedtime and for naps, the mask was not stored according to guidelines. Interviews with staff indicated a lack of proper storage practices, as the C-PAP mask should have been stored in a respiratory bag when not in use. Similarly, Resident 20's nasal cannula tubing was observed improperly stored, with the tubing and respiratory storage bag found on the floor and intertwined. The resident was ordered to wear oxygen continuously, yet the equipment was not maintained in a sanitary manner. Staff interviews confirmed that the oxygen tubing should not have been dragging on the floor and should have been stored in a respiratory bag. The facility's policy did not include specific guidelines for the storage of oxygen and C-PAP equipment, contributing to the improper handling of these devices.
Failure to Monitor Pain Medication Effectiveness
Penalty
Summary
The facility failed to ensure the effectiveness of pain medications was monitored for a resident who required such services. The resident, who had diagnoses including diabetes, anxiety, kidney failure, and polyneuropathy, reported experiencing pain upon movement and was prescribed Tramadol 50 mg every 6 hours for pain management. Despite the resident's care plan indicating the need to monitor the effectiveness of pain medications, the Medication Administration Records (MAR) for November, December, and January lacked documentation showing that the effectiveness of Tramadol was monitored. The effectiveness box on the MAR was marked out for the entire duration of these months. During an interview, a registered nurse confirmed that the effectiveness of the pain medication should have been documented. The facility's policy on pain management, provided by the Assistant Director of Nursing, stated that the effectiveness of administered pain medication should be documented 1-2 hours post-administration. However, this policy was not adhered to, leading to the deficiency in monitoring the resident's pain management effectively.
Failure to Complete Pre/Post Dialysis Assessments
Penalty
Summary
The facility failed to ensure that pre and post dialysis assessments were completed for a resident who required dialysis services. The resident, who had chronic kidney disease stage 4, anemia in chronic kidney disease, and acute kidney failure, was scheduled to attend dialysis sessions three times a week. Despite this, there were multiple instances where pre and post dialysis assessments were not completed, as evidenced by missing assessments on specific dates in November and December 2024. This lack of documentation was confirmed during an interview with a registered nurse, who stated that these assessments were necessary for communication between the facility and the dialysis center. The resident's care plan highlighted the risk of fluid volume deficit and excess related to dialysis treatment, with specific interventions to monitor for symptoms such as hypotension, tachycardia, and weight gain. However, the absence of pre and post dialysis assessments indicates a failure to adhere to these care plan interventions. The facility's policy on post hemodialysis care outlined conditions under which a physician should be notified and described emergency situations related to dialysis patients, emphasizing the importance of continuous management of the disease causing renal failure. The failure to complete these assessments could potentially compromise the resident's health and safety, as critical signs and symptoms may go unnoticed.
Failure to Adjust Medication Based on Lab Results
Penalty
Summary
The facility failed to adjust a resident's medication regimen in response to laboratory results, leading to a deficiency in ensuring the drug regimen was free from unnecessary drugs. Resident 32, who had diagnoses including underweight, disorientation, muscle weakness, and osteoarthritis, was prescribed cholecalciferol 10,000 units daily for vitamin D deficiency. A laboratory test conducted on the resident showed a vitamin D level greater than 120 ng/mL, which exceeded the normal range of 30-100 ng/mL. Despite this elevated level, the nurse practitioner's progress notes did not address the high vitamin D level, and the medication dosage was not adjusted accordingly. During an interview, the nurse practitioner stated a preference for vitamin D levels between 30-80 ng/mL and indicated that she would decrease the medication if levels exceeded 100 ng/mL. However, she also mentioned that a high vitamin D level was not harmful, which contradicts professional references indicating potential harm from excessive vitamin D. The facility's policy required the charge nurse to monitor lab results and ensure they were reported to the physician, but this process was not effectively followed, contributing to the deficiency.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to adhere to the 14-day limit for as-needed (PRN) psychotropic medication use for a resident diagnosed with major depressive disorder and adjustment disorder with depressed mood. The resident, who had moderate cognitive impairment, was prescribed Xanax for anxiety on an as-needed basis. However, the medication was administered beyond the 14-day limit without proper documentation or evaluation by a physician to justify the extended use. The Medication Administration Record showed that the resident received Xanax on multiple occasions beyond the 14-day period. Interviews with facility staff revealed a lack of awareness regarding the time limits for PRN psychotropic medications. The RN interviewed was unaware of the limitations, and the facility's drug reviews for psychotropic medications were conducted every six months, which may not have been sufficient to address the issue in a timely manner. Additionally, the Nurse Practitioner and Director of Nursing acknowledged that the resident had been to the emergency room multiple times, and the emergency room physician had prescribed Xanax for shortness of breath, but no progress note was completed to justify the continued use of Xanax beyond the 14-day limit. The facility's policy required PRN orders for psychotropic drugs to be limited to 14 days unless a physician documented the rationale for extending the medication, which was not done in this case.
Failure to Maintain Nutritive Value in Pureed Diets
Penalty
Summary
The facility failed to ensure the nutritive value and flavor of pureed diets for two residents who received such diets. During an observation of food preparation, the Dietary Manager was seen preparing pureed carrots by blending cooked carrots with water but failed to add chicken base as per the instructions. The instructions, which were taped inside a cabinet door, specified the addition of chicken base, hot water, and thickener for pureed vegetables. The Dietary Manager acknowledged the omission of the chicken base during an interview. The facility's policy on consistency-modified foods was provided, indicating that recipes should be prepared as given unless otherwise stated.
Inadequate Infection Control Practices for Residents on EBP
Penalty
Summary
The facility failed to ensure proper infection control practices for residents on Enhanced Barrier Precautions (EBP). During a medication administration observation, a registered nurse entered the room of a resident with an EBP sign and an isolation cart, wearing only gloves and not a gown, as required. The resident had a PEG tube, and the care plan indicated the need for EBP due to the device. The nurse admitted to not wearing the necessary gown during the medication administration. Additionally, two certified nursing assistants (CNAs) were observed not following EBP protocols. One CNA entered a resident's room without any personal protective equipment (PPE) and provided morning care, despite a sign indicating the need for PPE. Another CNA handled a resident's urinary catheter drainage bag, which was leaking, wearing only gloves and not changing them between tasks. Both CNAs acknowledged the requirement for additional PPE when providing care to residents on EBP but failed to comply. The facility's policy, provided by the Regional MDS Consultant, outlined the need for gloves and gowns during high-contact activities, which was not adhered to in these instances.
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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 Syracuse
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avalon Village | 7.6 mi | ★★★★★ | 25 | 0 |
| Waterford Crossing | 9.6 mi | ★★★★★ | 6 | 0 |
| Greencroft Healthcare | 10.8 mi | ★★★★★ | 4 | 0 |
| Majestic Care Of Goshen | 10.8 mi | ★★★★★ | 6 | 0 |
| Restoracy Of Goshen, The | 12.1 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.