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 Finger Lakes Center For Living during CMS and state inspections, most recent first.
Staff reported that a CNA roughly handled and sprayed perfume on a cognitively impaired, dependent resident during combative care, and made a callous remark about another resident dying on the commode in front of that resident. The on-duty RN supervisor did not treat this as suspected abuse, did not complete or document an RN assessment, and allowed the CNA to continue working for several hours. During the same shift, the same CNA was reported by another CNA and a roommate to have been rough and verbally demeaning with a second cognitively impaired, non-ambulatory resident, causing the resident to cry out, but the LPN who received the report did not escalate it or obtain an RN assessment. The CNA remained on the unit with access to residents until later suspension, and RN assessments for both residents were delayed and not completed at the time of the incidents.
Staff failed to timely report and act on witnessed verbal and physical abuse by a CNA toward two residents with severe cognitive impairment and significant physical limitations. In the first incident, a CNA roughly handled a resident, sprayed perfume on them during combative care, and made a verbally abusive remark; this was reported to an RN supervisor who did not assess the resident, did not initiate an incident report, and left the shift without fully following up, while the CNA continued caring for residents. Later the same day, the same CNA was reported by another CNA to have been rough and verbally inappropriate with a second resident who was repeatedly trying to get out of bed; this concern was reported only to an LPN, who did not escalate it to a supervisor. The DON and administrator were not notified of either incident until hours after the first allegation, contrary to the facility’s abuse reporting policy, and the CNA was not removed from resident care until later that evening.
A resident admitted for rehabilitation after a fracture did not receive a prescribed anticoagulant due to failures in medication reconciliation and verification by nursing and provider staff. The omission was not identified during multiple checks, and the resident was later hospitalized with a deep vein thrombosis.
A resident admitted for rehabilitation following fractures did not receive a prescribed anticoagulant due to a failure in medication reconciliation and order clarification. The omission was only discovered after the resident developed DVT and was hospitalized. The facility did not report the significant medication error to the State Agency within the required timeframe, as required by policy and regulation.
A resident with pneumonia and a physician's order for oxygen at bedtime did not receive the prescribed oxygen therapy when an LPN signed off on administration but failed to apply the nasal cannula and turn on the oxygen. The omission was discovered when the resident was found in respiratory distress with low oxygen saturation, leading to emergency interventions and transfer to the emergency department.
Multiple allegations of abuse and neglect were not thoroughly investigated after several residents and staff reported that two CNAs yelled and used profanities during care, causing distress to residents. There was no timely assessment by qualified professionals, required notifications were not made, and the accused staff continued to work after the incidents, contrary to facility policy.
The facility's main kitchen was found to have multiple deficiencies in food safety practices, including unclean areas, expired and undated food, and improper storage during a survey. The kitchen had grease buildup, food debris, and moldy food items, indicating a failure to adhere to the facility's policies on food storage and infection control. The Manager of Nutrition Services acknowledged responsibility but noted lapses in staff adherence to protocols.
The facility failed to consistently document refrigerator temperatures in the Interlaken medication room, as required by policy. Several dates in August 2024 were missing temperature records, and some entries were filled in without verification. Staff interviews confirmed the incomplete logs, and the administrator emphasized the importance of monitoring temperatures to ensure medication effectiveness.
Two residents did not receive meals that met their dietary needs due to missing or incorrect items on their trays. One resident, with severe cognitive impairment and dysphagia, did not receive fortified potatoes necessary for their nutritional intake. Another resident, with diabetes, received regular Pepsi instead of Diet Pepsi and had missing items on their tray. Staff interviews indicated frequent issues with meal tray accuracy and a lack of communication with the kitchen to address these problems.
The facility did not comply with regulations by allowing the Acting DON to also serve as a Unit Manager while the facility census was 75 residents. The Acting DON had been in both roles since December, working extended hours, and the Administrator was unaware of this dual assignment.
Failure to Immediately Protect Residents and Obtain RN Assessments After CNA Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement immediate protective measures and RN assessments after witnessed verbal and physical abuse by a CNA toward two residents. For the first resident, who had aphasia, hemiplegia, anxiety disorder, severely impaired cognition, limited range of motion, and required substantial to maximal assistance with ADLs, multiple CNAs reported that the resident became combative during care and that the assigned CNA handled the resident roughly and sprayed perfume on the resident while they were resisting care. One CNA reported seeing the perfume sprayed at the resident and hearing the abusive comment that another resident might “die on the commode,” made in front of this resident. Another CNA reported seeing the perfume sprayed over the resident’s body after care. The facility’s own investigation later characterized this as rough treatment and spraying cologne over the resident’s head and into their eyes while the resident tried to hit and push the CNA away. Despite this information, the on-duty RN supervisor did not conduct or document an RN assessment of the first resident at the time of the incident. The CNA who witnessed the event reported it to the RN supervisor between approximately 4:00 PM and 4:45 PM, and the RN supervisor acknowledged being told that perfume had been sprayed and that the resident slapped the CNA away. The RN supervisor stated they did not believe abuse had occurred, did not interview the other CNA who wanted to report the incident, and did not complete or document a nursing assessment, although they recalled transporting the resident to the dining room and observing them as “fine and smiling.” The RN supervisor left at the end of their shift at 7:00 PM without escalating the concern as suspected abuse. The DON was not notified until approximately 7:49 PM by an LPN, and the CNA alleged to have committed the abuse was not suspended and removed from resident care until about 8:00 PM, several hours after the initial report. The second resident involved had osteoarthritis, a knee replacement, Alzheimer’s disease, severely impaired cognition, used a wheelchair, had lower extremity impairment on one side, and was dependent for rolling and sit-to-stand and did not ambulate. During the same evening, the same CNA assigned to this resident was reported by another CNA and the resident’s roommate to have been verbally rude and curt, telling the resident they were not going to do the “up and down” with transfers all night, and to stay in bed. The assisting CNA described the CNA as rough when placing an arm under the resident’s arm and lifting the resident’s legs into bed, causing the resident to cry out in pain, and reported that the CNA leaned down toward the resident and repeated that they were tired of the “up and down game.” This was reported to an LPN, who spoke with the roommate and confirmed the account but did not consider it verbal abuse and did not report it to a supervisor. No RN assessment of the second resident was completed that evening, and the DON’s assessment was documented only on a later date without a time. The facility’s investigation later concluded that both physical and verbal abuse had occurred toward both residents, but at the time of the incidents, the CNA remained on duty with access to residents until being sent home around 8:00 PM, and no immediate RN assessments were documented for either resident.
Removal Plan
- All staff currently working in the facility (including staff who are employed by the hospital and work on the nursing home side) have been educated on Abuse, Identification of Abuse, and Reporting of Abuse.
- Provide education to any staff on leave prior to the start of their shift.
Failure to Timely Report and Act on Witnessed Verbal and Physical Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to timely report and respond to witnessed verbal and physical abuse incidents, allowing the alleged perpetrator to continue providing resident care. Facility policy required that when abuse was identified, the facility immediately protect residents from additional abuse, begin an investigation, and initiate reporting through the shift supervisor or charge nurse. On the date in question at approximately 4:00 PM, a CNA witnessed another CNA handle a resident roughly, spray perfume on the resident when they were combative with care, and make a verbally abusive statement. The witnessing CNA reported the incident to the RN supervisor, but the RN supervisor did not assess the resident and did not initiate the required abuse reporting and investigation process at that time. Resident #1 had diagnoses including aphasia, hemiplegia, and anxiety disorder, with severely impaired cognition and dependence on substantial to maximal assistance for most ADLs. Around 4:00 PM, two CNAs were providing care when the resident became combative. One CNA reported seeing, and another smelling and partially seeing, the alleged perpetrator CNA spray perfume on the resident’s clothes multiple times, and one CNA heard the verbally inappropriate comment about another resident possibly dying on the commode. The witnessing CNA reported the incident to the RN supervisor before supper and informed the supervisor that another CNA also needed to speak with them. The RN supervisor, who usually worked on the hospital side, acknowledged being aware of the report and that another CNA wanted to speak, but did not complete an incident report, did not fully interview all witnesses, and left the shift at 7:00 PM without following up. The DON was not notified until approximately 7:49 PM by an LPN who learned of the incident around 7:30 PM, and the alleged perpetrator CNA was not suspended until approximately 8:00 PM. During the period between the initial 4:00 PM report and the 8:00 PM suspension, the alleged perpetrator CNA continued to have access to residents and was involved in a second incident with another resident after supper. Resident #2 had osteoarthritis and Alzheimer’s disease, with severely impaired cognition, wheelchair use, lower extremity impairment, and dependence for mobility. After supper, a CNA reported that the same CNA was rough with Resident #2 while putting them to bed and told the resident they were not going to play the “up and down game” all night. This was reported by the CNA to an LPN, who did not escalate the concern to a nursing supervisor because they believed the behavior was only verbally inappropriate and similar to how many CNAs spoke, and they stated there was no supervisor available after the RN supervisor left at 7:00 PM. The DON later documented being notified of the incident involving Resident #2 at 7:49 PM, and the Administrator acknowledged that the incidents involving both residents were not reported to the DON until about 8:00 PM, contrary to the facility’s abuse reporting policy. The surveyors found no documentation that the 4:00 PM witnessed incident with Resident #1 or the after-supper incident with Resident #2 were reported immediately to a nursing supervisor or the Administrator as required. Interviews with the Administrator, DON, RN supervisor, CNAs, and LPNs confirmed delays in reporting, incomplete follow-up by the RN supervisor, and continued resident access by the alleged perpetrator CNA until suspension at approximately 8:00 PM. The facility’s failure to timely report and act on these abuse allegations, and to immediately protect residents from further potential abuse, was cited as Immediate Jeopardy and Substandard Quality of Care affecting all residents in the facility.
Removal Plan
- All staff currently working in the facility have been educated on abuse, identification of abuse, and reporting of abuse.
- Provide education to any staff on leave prior to the start of their shift.
Failure to Administer Anticoagulant on Admission Leads to Harm
Penalty
Summary
A deficiency occurred when a resident was admitted to the facility following a hospital stay for a left femoral fracture. The hospital discharge summary and medication reconciliation order report both indicated that the resident was to receive Eliquis, an anticoagulant, at a specified dose. However, upon admission, the medication was not ordered, and the resident did not receive any anticoagulant therapy during their stay at the facility. The admitting nurse accessed the hospital records and noted the medication reconciliation order form but did not review the discharge summary or clarify questions about the anticoagulant order. The nurse placed the medication reconciliation form on the nurse practitioner's desk without notifying them of any concerns. The nurse practitioner reviewed and signed off on the orders entered into the computer but did not compare the discharge summary and medication reconciliation order form against the orders entered. A third nurse, responsible for the final check, only reviewed the orders in the medical record and did not reference the original hospital documents. As a result, the omission of the anticoagulant was not detected by any of the staff involved in the admission process. The resident subsequently developed edema in the lower extremity and was sent to the hospital, where a deep vein thrombosis was diagnosed. Interviews with facility staff revealed that the established protocols for medication reconciliation and double-checking high-risk medications, such as anticoagulants, were not followed. The failure to clarify and verify the resident's medication orders led to the resident not receiving a critical medication, resulting in actual harm.
Removal Plan
- Educate nursing staff to not view or print the discharge summary or medication reconciliation order form until a resident is discharged from the hospital.
- Transcribe medication from the discharge summary or medication reconciliation order form by the admitting nurse for each new admission or re-admission.
- Review medication orders by the advanced practice provider.
- Review medication orders by a second nurse.
- Review medication orders by the Director of Nursing.
- Review medication orders by a licensed pharmacist.
- Provide staff education based on an education outline.
Failure to Timely Report and Address Medication Omission Leading to DVT
Penalty
Summary
A significant medication error occurred when a resident was admitted to the facility following a hospital stay for fractures and was prescribed an anticoagulant (Eliquis) as part of their discharge medications. Despite the hospital discharge summary and medication reconciliation order clearly listing the anticoagulant, there was no documented evidence that the medication was ordered or administered upon admission or during the resident's stay. The resident did not receive the prescribed anticoagulant from the time of admission until they were transferred back to the hospital. The omission was discovered after the resident developed edema in the lower extremity and was sent to the hospital, where they were diagnosed with deep vein thrombosis (DVT). Investigation revealed that a registered nurse had sought clarification regarding the anticoagulant order but did not ensure the medication was provided. The facility's documentation showed that the medication omission was not identified or addressed until after the resident's hospital readmission and diagnosis of DVT. Furthermore, the facility failed to report the significant medication error to the New York State Department of Health within the required timeframe. The Director of Nursing and the Administrator were notified of the incident several days after the resident's transfer, and there was uncertainty regarding which entity was responsible for reporting. The incident was ultimately reported to the State Agency, but not in a timely manner as required by state regulations and facility policy.
Failure to Provide Ordered Oxygen Therapy Results in Resident Respiratory Distress
Penalty
Summary
A deficiency occurred when a resident with a history of pneumonia and cerebral vascular accident, who had a physician's order for oxygen at bedtime due to hypoxia, did not receive the ordered respiratory care. The resident required oxygen at 2 liters/minute via nasal cannula at bedtime, as documented in the medical record and care plan. On the evening in question, the LPN responsible for administering medications and treatments signed off in the Medication Administration Record that the oxygen was applied, but later admitted to forgetting to place the nasal cannula on the resident and to turn on the oxygen. The resident was found later that night by staff in respiratory distress, with an oxygen saturation of 54% on room air and without the nasal cannula in place. The oxygen tubing was observed to be attached to the wall regulator, but the oxygen was not turned on. Immediate interventions were initiated by nursing staff, including increasing oxygen flow, administering a breathing treatment, and applying a non-rebreather mask, but the resident's oxygen saturation remained low. The resident was subsequently transferred to the emergency department for evaluation and treatment of respiratory distress. Interviews with staff confirmed that the LPN had signed for the administration of oxygen without actually providing it, and that the omission was not discovered until the resident was found in distress. The facility's policy required verification and administration of oxygen as ordered, as well as monitoring for signs of hypoxia, but these steps were not followed. The incident was documented in the facility's incident report and confirmed through staff interviews and medical record review.
Failure to Investigate and Respond to Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate and respond to multiple allegations of abuse and neglect involving four residents. On the date in question, two certified nurse aides were alleged to have yelled at a resident during care, as reported by the resident's roommate, who also developed a headache from the incident and required pain medication. There was no documentation that the affected residents were assessed by a qualified professional following the allegations, and the incident was not promptly reported to the facility Administrator or the New York State Department of Health as required by policy. Further, another certified nurse aide reported that while providing care to a different resident, the same two aides entered the room, yelled, and used profanities, upsetting the resident. Again, there was no evidence that this resident or their roommate, who was present during the incident, were assessed by a qualified professional. Staff statements from the accused aides and other involved personnel were either missing or delayed, and there was no documentation that the accused aides were suspended from duty immediately after the allegations, as required by facility policy. The residents involved had varying degrees of cognitive impairment, with some being severely impaired and others cognitively intact. Despite clear reports from residents and staff about yelling, rough handling, and inappropriate language, the facility did not initiate timely assessments, failed to suspend the accused staff, and did not ensure that all required notifications and documentation were completed. These failures were in direct violation of the facility's abuse prevention and management policy and state regulations.
Deficiencies in Food Safety Practices in Facility Kitchen
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. During the recertification survey, multiple unclean areas were observed, including grease buildup on kitchen hoods and the back wall, food debris on the floor, and grime around the deep fryer. Additionally, the cooking area cooler contained undated wrapped sandwiches, and the walk-in meat cooler had undated cooked ground beef. The walk-in freezer had dripping condensation and ice buildup, and expired food items such as apple cider vinegar, hot dog rolls, and dinner rolls with mold were found on the food storage rack. The storage bin in the walk-in cooler contained spoiled lettuce, spinach, and a mushy cucumber. The facility's policies on food storage and infection control were not adhered to, as evidenced by the lack of proper dating and rotation of food items, and inadequate cleaning of work areas and storage units. The Manager of Nutrition Services acknowledged responsibility for maintaining a clean kitchen and stated that a janitor was scheduled to clean the kitchen nightly. However, the manager also indicated that staff were responsible for cleaning spills and discarding moldy food, and that the Assistant Manager should oversee inventory management. Despite these protocols, the survey revealed significant lapses in food safety practices, leading to the observed deficiencies.
Medication Storage Temperature Documentation Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to accepted professional principles in one of its medication rooms, specifically the Interlaken medication room. During the recertification survey, it was observed that the refrigerator temperatures in this medication room were not consistently documented. The facility's policy required that medication refrigerator temperatures be recorded twice daily, once in the morning and once in the evening. However, there were several instances in August 2024 where temperatures were not documented for both day and evening shifts. Interviews with staff revealed that the temperature logs were incomplete, and some temperatures were filled in without verification. A Licensed Practical Nurse acknowledged the missing dates and noted that the log for August 2024 was missing from the binder. A Registered Nurse Unit Manager admitted to filling in temperatures for missing dates without knowing the actual temperatures, which could not be verified. The facility administrator confirmed that monitoring and documenting refrigerator temperatures were crucial to ensure medication effectiveness, and medications should not be administered if temperatures were not monitored. The deficiency was identified under 10NYCRR 483.45 (g)(h).
Deficiency in Meeting Residents' Dietary Needs
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that met the daily nutritional needs of two residents, as observed during a recertification survey. Resident #29, who had severe cognitive impairment and was dependent on staff for eating, was on a ground solid diet with honey thickened liquids due to dysphagia. Despite a care plan that included fortified potatoes to address significant weight loss, these were missing from the resident's meal tray. The absence of fortified potatoes, which were crucial for the resident's caloric and nutritional intake, was not addressed by the staff, as they failed to notify the kitchen to rectify the omission. Resident #50, who was moderately cognitively impaired and had diabetes, reported that their food was not hot and lacked flavor. During an observation, their meal tray was missing low-calorie cranberry juice and yogurt, and it contained regular Pepsi instead of Diet Pepsi, which was against their dietary preferences and needs. The corn served was overcooked and difficult to chew. Staff interviews revealed that meal trays often had missing or incorrect items, and there was a lack of communication with the kitchen to correct these issues, leading to deficiencies in meeting the residents' dietary requirements.
Non-Compliance with Director of Nursing Role Requirements
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) served solely in their designated role when the facility's average daily occupancy exceeded 60 residents. Specifically, the Acting Director of Nursing #2 was also functioning as the Unit Manager for the Stillwater Unit, despite the facility having a census of 75 residents at the time of the survey. This dual role was not in compliance with the regulatory requirement that the DON should not serve as a unit manager unless the facility has 60 or fewer residents. The Acting Director of Nursing #2 had been performing both roles since December 2023, working 10-11 hours daily to fulfill the responsibilities of both positions. The facility's Administrator was unaware of this dual role assignment and acknowledged it as an error. The Acting Director of Nursing #2 was set to transition to the Assistant Director of Nursing position, but the Director of Nursing position had not yet been posted. There were no nurse waivers in place to justify the dual role.
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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.
Illustrative
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Illustrative
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Nursing homes near Auburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Commons On St Anthony, A S N F & Short T R C | 1.9 mi | ★★★★★ | 0 | 0 |
| Auburn Rehabilitation & Nursing Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Seneca Nursing & Rehabilitation Center, Llc | 14.5 mi | ★★★★★ | 0 | 0 |
| Northwoods Rehab And Nursing Center At Moravia | 17.3 mi | ★★★★★ | 14 | 0 |
| Syracuse Home Association | 17.8 mi | ★★★★★ | 12 | 0 |
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