Above 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 Good Samaritan Society - Syracuse during CMS and state inspections, most recent first.
A long-term care facility failed to follow proper hand hygiene and gloving techniques during wound care and tube feeding, did not implement Covid-19 prevention measures, and lacked a Legionella water management plan. Observations revealed that staff did not wash hands between glove changes, placed supplies directly on beds, and left doors open in Covid-19 positive rooms. Additionally, tube feeding supplies were improperly stored, and there was no documented water management program to prevent Legionella growth.
Facility staff failed to notify the physician and responsible party about missed doses of Phenytoin for a resident with severe mental impairment. The resident missed 19 doses over two months due to medication unavailability. The Clinical Care Leader confirmed that the pharmacy was not alerted, and the physician and Power of Attorney were not informed, violating the facility's policy.
A resident at risk for elopement due to dementia had a wander guard system placed on their wrist, but the MDS did not reflect this use. The error was confirmed by the MDS Coordinator, who acknowledged the oversight in coding. The resident's CCP documented the use of the wander guard, but the MDS failed to accurately capture this intervention.
A facility failed to re-evaluate a resident's elopement risk and monitor the wander guard system. The resident, with severe cognitive impairment, had a wander guard initiated due to exit-seeking behavior, but checks were not documented due to system errors. Staff interviews confirmed the oversight in monitoring and documentation.
A resident with epilepsy experienced a significant medication error due to the unavailability of Phenytoin Oral Suspension for 19 doses over two months. Facility staff failed to notify the pharmacy about the shortage, contrary to the facility's medication ordering policies. The resident's POA was aware of the issue, and the Clinical Care Leader acknowledged the oversight.
Infection Control and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene and gloving techniques during wound care for Resident 34 and tube feeding for Resident 17. During an observation of wound care for Resident 34, the Clinical Care Lead (CCL) did not wash their hands or use hand sanitizer between glove changes. The CCL also placed wound care supplies directly on the resident's bed without a barrier and used unclean scissors to cut both dirty and clean dressings. These actions were confirmed by the CCL as breaches of the facility's hand hygiene policy. In addition, the facility did not implement necessary interventions to prevent the spread of Covid-19. Observations revealed that doors to rooms with Covid-19 positive residents were left open, contrary to the facility's policy and CDC guidelines, which require doors to be kept closed to prevent airborne transmission. The Clinical Care Lead confirmed this as an infection control breach. Furthermore, the facility lacked a Legionella water management plan. The Maintenance Director and Facility Administrator were unable to provide a water flow diagram or confirm the existence of a water management program team. This deficiency was in violation of the facility's policy, which requires a documented water management program to prevent the growth of Legionella. Additionally, during tube feeding for Resident 17, an LPN failed to perform hand hygiene after touching potentially contaminated items, such as keys stored in their pocket, and stored tube feeding supplies on the floor, which was confirmed as inappropriate by the Clinical Care Lead Coordinator.
Failure to Notify Physician and Responsible Party of Missed Medication Doses
Penalty
Summary
The facility staff failed to notify the physician and responsible party regarding missed and unavailable doses of medication for a resident. The resident, identified as having severe mental impairment, was assessed for the use of anticonvulsant medication, specifically Phenytoin Oral Suspension, which was prescribed to be administered twice daily. A review of the Medication Administration Record revealed a total of 19 missed doses over November and December 2024, with 16 doses missed in November due to the medication being unavailable and 3 doses missed in December for the same reason. An interview with the Clinical Care Leader confirmed that the staff did not alert the pharmacy about the unavailability of the medication and failed to notify the physician or the resident's Power of Attorney about the missed doses. The facility's policy, dated December 23, 2024, mandates immediate notification of the resident, consultation with the resident's physician, and notification of the resident representative in such situations. However, this protocol was not followed, leading to the deficiency identified in the report.
MDS Coding Error for Wander Guard System
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) for a resident accurately reflected the use of a wander guard system. The resident, who was at risk for elopement due to dementia, had a wander guard system placed on their wrist on December 19, 2024. This was confirmed by the facility's Social Worker and documented in the resident's Comprehensive Care Plan (CCP). However, the MDS, which was reviewed for the period between December 20, 2024, and December 26, 2024, did not indicate the use of a wander guard system, despite the resident's known risk for wandering and elopement. The MDS Coordinator confirmed that there was an error in the MDS coding, as the wander guard system was not correctly documented in Section P0200 E of the MDS. This oversight was identified during a record review and interviews with facility staff. The facility's Order Listing Report indicated that a total of 11 residents had orders for a wander guard system, but the deficiency was specifically noted for this resident, highlighting a lapse in accurately coding the resident's assessment data.
Failure to Monitor Wander Guard System and Re-evaluate Elopement Risk
Penalty
Summary
The facility failed to re-evaluate the elopement risk and monitor the functioning of the wander guard system for a resident with severe cognitive impairment. The resident, diagnosed with Unspecified Dementia, Depression, and Generalized Anxiety Disorder, was identified as having a potential for elopement due to exit-seeking behavior. Despite this, the resident's elopement risk assessment had not been updated since June, and the wander guard system, which was supposed to be checked twice daily, was not documented as being checked since its initiation in December. Interviews with facility staff revealed that the wander guard checks were not documented in the Electronic Medication Administration Record (MAR) or Treatment Administration Record (TAR) due to the order not populating in the system. This oversight led to the wander guard system checks not being completed or documented as required. The Clinical Care Lead Coordinator confirmed that an elopement assessment should have been completed when the wander guard was initiated, but it was not, contributing to the deficiency in monitoring and ensuring the resident's safety.
Failure to Ensure Availability of Anticonvulsant Medication
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of epilepsy was free from significant medication errors. The resident's Medication Administration Record (MAR) indicated that Phenytoin Oral Suspension, prescribed to manage epilepsy, was unavailable for a total of 19 doses over November and December 2024. This lapse in medication availability was not promptly addressed by the facility staff, as they did not notify the pharmacy about the shortage, leading to a significant medication error. Interviews revealed that the resident's Power of Attorney (POA) was aware of the medication unavailability but could not specify when they were informed. The Clinical Care Leader confirmed that the staff failed to notify the pharmacy about the missing medication. The facility's policies required licensed nursing employees to order medications and report discrepancies to the pharmacy and charge nurse, which was not adhered to in this case.
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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) |
|---|---|---|---|---|
| The Ambassador Nebraska City, Inc | 16.9 mi | ★★★★★ | 1 | 0 |
| Prestige Care Center Of Nebraska City | 17.4 mi | ★★★★★ | 13 | 0 |
| Southlake Village Rehabilitation & Care Center | 21.5 mi | ★★★★★ | 8 | 0 |
| Hillcrest Firethorn | 22.5 mi | ★★★★★ | 0 | 0 |
| Nye Summit | 22.8 mi | ★★★★★ | 0 | 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.