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 Iroquois Nursing Home Inc during CMS and state inspections, most recent first.
A resident with dementia and recent hip fracture surgery was admitted on a PRN quetiapine order for agitation, which the facility continued and administered multiple times without a behavior care plan, without documented target behaviors, and without evidence that non-pharmacological interventions were attempted or that medication effectiveness was assessed. Facility policy required identification of underlying causes of behaviors, individualized non-drug interventions, and clear indications and documentation for PRN psychotropics, but the resident’s care plan addressed only potential adverse effects of antipsychotic use and did not include specific behavioral interventions. The MAR and progress notes lacked behavior descriptions and follow-up for most PRN doses, while the resident’s proxy reported excessive daytime sleepiness and difficulty obtaining information about the medication, and staff interviews revealed inconsistent practices and rationales for using PRN antipsychotics, including use for agitation and sleep without clearly documented medical necessity.
The facility did not maintain a safe and homelike environment on Unit 1, as several residents were found in unclean and damaged chairs. Staff interviews revealed a lack of awareness and communication regarding the condition of the chairs, with no recent work orders submitted for repairs, despite the facility's policy requiring maintenance of resident equipment.
A resident with dementia and anxiety was improperly restrained using a Merry Walker without adequate documentation or parameters for its use. The resident could not release themselves from the device, and staff failed to document restraint release intervals. The care plan lacked necessary interventions, and the resident's family raised safety concerns.
A resident with limited mobility was not evaluated by therapy or care planned for the use of a scoot chair, despite using it for about two months. The facility's policies required documentation and evaluation of such devices, but the care plan was not updated, and no therapy referral was obtained. Staff interviews revealed a lack of communication and coordination between nursing and therapy, resulting in the deficiency.
A resident with end-stage renal disease did not have a comprehensive care plan addressing dialysis needs, despite having physician orders and specific care instructions. Facility staff acknowledged the absence of a dialysis care plan and the failure to follow medical orders, leading to a deficiency in providing appropriate dialysis care.
A resident with Alzheimer's and anxiety, dependent on staff for toileting, was not assisted according to their care plan. Despite being moved around the facility, the resident was not toileted from early morning until the afternoon. Staff admitted to inconsistencies in care provision and documentation due to staffing issues, leading to a deficiency in care.
The facility failed to post daily nurse staffing information at the beginning of each shift, as required, during a survey. Observations showed outdated or missing staffing information on multiple days. Interviews revealed a lack of policy and awareness among staff, contributing to the deficiency.
PRN Antipsychotic Administered Without Indication, Behavior Care Plan, or Required Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs, specifically related to PRN antipsychotic use without adequate medical rationale or documentation. Facility policy on psychotropic medication required identification of underlying causes of behaviors, use of individualized non-pharmacological interventions, and clear indications for PRN antipsychotics, including specific target symptoms and documentation of post-medication effects. Despite this, the resident’s records did not contain a behavior care plan or personalized behavioral interventions, and the Resident Care Record lacked any information on behavioral symptoms or related interventions. The resident had diagnoses including unspecified dementia with behavioral disturbance and osteoporosis with a pathological hip fracture, and an MDS assessment documented severely impaired cognition, no behaviors, and a need for partial to moderate assistance with most ADLs. A comprehensive care plan addressed potential adverse effects from daily antipsychotic use but did not list an associated diagnosis and did not include a separate behavior care plan. The resident was admitted from the hospital with a PRN quetiapine order for agitation when unable to be redirected and with harm to self and others, and the facility’s admission orders continued quetiapine 12.5 mg PO in the evening as needed for 14 days. The NP’s history and physical documented dementia with behavior disturbances and other medical conditions and stated a plan to give PRN quetiapine for agitation, but there were no documented behaviors or related diagnosis specifically tied to the quetiapine in the record. The MAR showed the resident received PRN quetiapine on four occasions, yet there was no documentation of behaviors, non-pharmacological interventions attempted, or post-medication effectiveness for three of those administrations. A nursing progress note for one administration described restlessness, irritability, and reported aggression, with snacks, redirection, and incontinence care attempted, but did not specify the exact aggressive behaviors or the outcome after interventions and medication. The resident’s health care proxy reported difficulty keeping the resident awake, difficulty with eating coordination, and trouble obtaining information about medications, and stated that quetiapine had been given at night without notes explaining why, despite the resident not typically exhibiting agitation or aggression. Interviews with staff revealed inconsistent understanding and practice regarding documentation and indications for PRN antipsychotic use: one LPN described giving quetiapine for aggression and attempts to leave, but acknowledged missing documentation; another LPN could not recall the reason for administration; the RN Unit Manager confirmed there was no behavior care plan and that notes were missing for most PRN uses; the NP stated agitation alone was not an indication and that non-pharmacological interventions and their effectiveness should be documented; the Medical Director indicated the drug was used for agitation and sleep and that PRN antipsychotics were routinely used for sleep; and the DON stated that if an as needed antipsychotic was administered, a corresponding nurse’s note was expected. Collectively, these findings show the resident received PRN antipsychotic medication without documented medical necessity, without required behavioral assessments and care planning, and without consistent documentation of non-drug interventions or medication effects, contrary to facility policy and regulatory requirements.
Failure to Maintain Clean and Safe Resident Equipment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents on Unit 1, as observed during a recertification survey. Multiple residents were found sitting in unclean and damaged positioning chairs and wheelchairs. Specific observations included unclean armrests, ripped chair material, and worn or soiled foam on armrests. The facility's policy required all resident devices and equipment to be maintained on a schedule, with defective or worn devices repaired or replaced. However, the observations indicated that this policy was not effectively implemented. Interviews with staff revealed a lack of awareness and communication regarding the condition of the chairs. Certified Nurse Aide #2 and Licensed Practical Nurse Manager #3 stated that all unit staff were responsible for cleaning and submitting work orders for repairs, but there were no recent work orders for the chairs in question. The Director of Nursing and the Director of Maintenance were also unaware of the issues, despite the expectation that staff would report any equipment needing repair. The failure to maintain the chairs in good condition compromised the facility's goal of providing a homelike environment for residents.
Improper Use and Documentation of Restraint for a Resident
Penalty
Summary
The facility failed to ensure that the use of a Merry Walker, evaluated as a restraint, was properly documented and used for the least amount of time necessary for Resident #7. The resident, diagnosed with dementia and anxiety, had a history of falls and was trialed with a Merry Walker to increase independence and safety. However, the Comprehensive Care Plan did not specify parameters for the use of the Merry Walker, and the restraint assessment was incomplete. Observations revealed that the resident was unable to release themselves from the Merry Walker, which was used continuously without documented intervals for release. Staff interviews indicated that there was no place to document the release of the restraint in the resident care instructions, and the care plan lacked interventions for the least restrictive use. The resident's family expressed concerns about the safety of the Merry Walker, especially in emergencies, as the resident could not release themselves. Interviews with facility staff, including the Director of Rehabilitation and a Nurse Practitioner, confirmed that the Merry Walker was considered a restraint and should be released every two hours. However, there was no documentation of such parameters in the physician's order or care plan. The facility's Administrator acknowledged that the Merry Walker was a restraint and required a physician's order with parameters for the least restrictive use, which was not in place for Resident #7.
Failure to Evaluate and Document Use of Scoot Chair for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services and equipment to maintain or improve mobility. Specifically, the resident, who had diagnoses including dementia, a fracture of the right femur, and a right hip replacement, was not evaluated by therapy or care planned for the use of a scoot chair. The resident's care plan did not document the use of a scoot chair, despite the resident being observed using one multiple times during the survey period. The facility's policies required that recommendations for devices, such as wheelchairs, be documented in the resident's care plan and that therapy services be requested to evaluate devices that were not properly fitting. However, the resident's care plan was not updated to reflect the use of a scoot chair, and no therapy referral was obtained for its evaluation. Interviews with staff revealed that the resident had been using a scoot chair for about two months, but there was no documentation or assessment to support its use. The deficiency was further highlighted by the lack of communication and coordination between nursing and therapy staff. Nursing staff did not submit a referral to therapy for the scoot chair, and therapy staff did not evaluate the resident for its use. Additionally, the care plan was not updated by either nursing or therapy to reflect the change in equipment, and a restraint assessment was not completed for the scoot chair, as required by facility policy.
Failure to Provide Comprehensive Dialysis Care Plan
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis services received care consistent with professional standards. Resident #301, who had end-stage renal disease and was dependent on renal dialysis, did not have a comprehensive care plan addressing their dialysis needs. Despite having physician orders for dialysis treatments and specific care instructions, the facility did not document a dialysis care plan or include necessary interventions for monitoring the dialysis site. The resident's care plan lacked information on dialysis, and there were no instructions for certified nurse aides regarding the resident's dialysis status. Interviews with facility staff revealed that there was a lack of communication and documentation regarding the resident's dialysis care. The Registered Nurse Unit Manager and the Assistant Director of Nursing acknowledged the absence of a dialysis care plan and the failure to follow medical orders. The Director of Nursing confirmed that the baseline care plan should have included the resident's dialysis needs, and it was crucial for certified nurse aides to have this information. The deficiency was identified during a recertification survey, highlighting the facility's failure to provide appropriate dialysis care for Resident #301.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary assistance with toileting. Resident #36, who had diagnoses including Alzheimer's dementia and anxiety, was dependent on staff for toileting and was supposed to be on a toileting schedule. However, during the survey, it was observed that the resident was not toileted as per their care plan. The resident was last documented to have been toileted at 5:50 AM, and despite being moved around the facility throughout the morning and early afternoon, they were not toileted again until 2:20 PM. Interviews with staff revealed inconsistencies in the provision and documentation of care. Certified Nurse Aide #22 admitted that due to staffing issues, residents were not always toileted as frequently as required, and documentation was not consistently completed. The Licensed Practical Nurse Manager and the Director of Nursing confirmed that the resident required substantial assistance with toileting and that failure to adhere to the toileting schedule could lead to skin breakdown and infections. The facility's policies and care plans were not followed, resulting in a deficiency in the care provided to Resident #36.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily at the beginning of each shift, as required by regulations, during the recertification survey conducted from August 14 to August 20, 2024. Specifically, the facility did not post the required nurse staffing information on four out of five days of the survey. Observations in the main lobby revealed that on August 14, 15, and 16, the posted nurse staffing information was outdated, showing the date of August 13, 2024, and only included the day shift staffing. On August 19, there was no staffing information posted in the morning, and it was only updated for the day shift later in the day. Interviews conducted during the survey revealed that the facility lacked a policy on posting daily nurse staffing. The Administrative Assistant/Day Staffing Coordinator was unaware that the posted staffing information was not current and suggested that the new evening shift staffing coordinator might have mishandled the schedule. Additionally, the night shift RN Supervisor was responsible for the night shift staffing schedule but had not been posting it in the lobby. The Administrator was also unaware of the deficiencies in posting the staffing schedule, indicating a lack of oversight and communication within the facility's staffing procedures.
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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 Jamesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Loretto Health And Rehabilitation Center | 1.3 mi | ★★★★★ | 20 | 0 |
| Nottingham R H C F | 1.9 mi | ★★★★★ | 7 | 0 |
| Van Duyn Center For Rehabilitation And Nursing | 2.5 mi | — | 54 | 6 |
| Upstate University Hosp At Community General T C U | 2.7 mi | ★★★★★ | 0 | 0 |
| Central Park Rehabilitation And Nursing Center | 3 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.