Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Jewish Home Of Central New York during CMS and state inspections, most recent first.
Failure to verify a resident’s ordered thickened liquids led to thin liquids being served at dinner. A resident with dementia, dysphagia, and end-of-life care orders was supposed to receive pureed food with pudding-thick liquids, but a CNA gave thin cranberry juice and water through a straw without checking with the nurse or task sheet. The LPN did not inspect the tray before service and did not escalate the family’s report that the tray contained thin liquids.
The facility failed to maintain proper food storage and sanitation practices in the kitchen. Observations found unlabeled and undated cooked meat and prepared foods, dented cans moved to an unlabeled shelf, and multiple refrigerators with dried food debris and poor repair. During dishwashing, staff filled the sanitizer bay with hot water instead of sanitizer, test strips did not register sanitizer, and dishes and utensils were washed and handled before proper sanitization. Staff also did not know the dish machine temperature requirements, and one worker began removing bowls for general use before the issue was stopped.
The facility failed to provide adequate ADL assistance with grooming, feeding, and clothing for three dependent residents. One cognitively intact resident with kidney failure and atrial fibrillation was repeatedly observed with unwanted facial hair and long, dirty fingernails despite stating they did not want facial hair and having care plans for grooming; a CNA admitted noticing the facial hair but not having time to shave the resident. Another resident with dementia and severe cognitive impairment, care planned for substantial assistance with a mechanically soft diet, received inconsistent and interrupted mealtime assistance, was often left asleep at the table, and had significant portions of meals and beverages left untouched before being removed from the dining area. A third resident with dementia and severe cognitive impairment, fully dependent on staff for dressing, was observed multiple times in visibly soiled clothing with food-like substances on their shirt and pants, even though staff acknowledged responsibility for changing soiled clothing and nursing leadership stated residents should not remain in soiled garments.
The facility failed to provide palatable, flavorful meals at safe and appetizing temperatures, as required by its own policy. During a lunch observation, a resident’s fried chicken and beverages were found below hot-holding standards and above cold-holding standards, and the food and drinks were described as bland and lukewarm. On another day at breakfast, two hospitalized residents received trays from meal carts, including one cart that had been marked as out of service but was still plugged in and used. Multiple hot items, such as egg and cheese croissants and pancakes, were served at substandard temperatures and tasted cold, while cold items like cottage cheese and milk were served warm. A CNA reported frequent complaints about cold food and the need to reheat meals, and dietary staff, including a food service worker and the food service director, confirmed that the observed temperatures for hot and cold foods were not acceptable.
A facility failed to provide individualized dementia care for two residents by not keeping care plans current with behavioral changes and by omitting interventions for cognitive decline and psychotropic medication use. One resident with Alzheimer’s disease, PTSD, and escalating behaviors had only general dementia interventions documented despite repeated agitation, paranoia, refusal of care, yelling, and aggression. Another resident with dementia and severe psychiatric features had no documented interventions for cognitive impairment or antipsychotic use, even though staff noted crying, aggression, poor redirection, and constant supervision needs.
Medication storage was not maintained according to accepted standards in several areas. An unlocked and unattended med cart was observed at the nurses’ station, and another cart contained an unlabeled insulin pen, bottles of vitamins without open or expiration dates, and unlabeled barrier cream tubes. In the second floor med room, barrier cream was stored improperly, and narcotic count sheets were illegible, making medication names and prescription numbers difficult to read.
A resident admitted with gangrene, peripheral vascular disease, and documented right foot and heel ulcers arrived with hospital orders for daily betadine-based wound care, offloading, and follow-up at a wound clinic for potential hyperbaric oxygen therapy. On admission, an RN noted a betadine dressing on the right toes but did not document wound characteristics or enter treatment orders, and no wound care orders were placed for 27 days. Facility policies required admission skin assessments, prompt wound orders, and referral to the wound team, but staff interviews showed confusion over who was responsible for entering orders. The DON and ADON stated orders should be taken from hospital paperwork within 48 hours, while the admitting RN reported not being taught how to place orders and the RN unit manager claimed the admitting RN was responsible. Meanwhile, an outside wound clinic appointment arranged by the family and recommended by the hospital was canceled at the direction of the CNO, who instructed staff not to let the resident leave until the in-house wound team evaluated the wounds, delaying both specialist care and timely wound management.
A memory care unit had a strong urine odor, stained and sticky floors, and dirty chairs observed by surveyors. Staff and a family member reported the unit often smelled of urine or old food, and housekeeping staff acknowledged the stained floor in a resident room and sticky substances on dining and sitting room chairs.
Failure to provide resident-preferred activities: A resident with dementia, Alzheimer’s disease, and major depressive disorder had documented preferences for music, pet visits, and holding baby dolls or stuffed animals, but was often observed seated without activities or staff interaction. The family said the resident did not seem to participate in activities, while the AD and activity aide acknowledged the resident’s interests but were unsure how often the resident was actually invited or involved in music and other preferred activities.
Improper garbage disposal and debris were observed around the trash compactor area. The facility’s garbage removal plan required dietary staff to remove bags properly and clean surrounding areas, but surveyors found food debris, wrappers, milk cartons, used gloves, and dirty utensils on the ground near the compactor. The FSD stated the debris was due to snow and plowing and acknowledged it should not be on the ground because it attracted pests.
A resident with diabetes and peripheral vascular disease did not receive routine podiatry care for eight months despite repeated recommendations from wound care and vascular providers. The facility lacked a documented process for obtaining podiatry consults, leading to missed nail care and ongoing foot issues. Staff interviews revealed confusion about responsibility for scheduling podiatry visits, and the resident's care plan did not address the need for podiatry services.
The facility failed to ensure ongoing provision of programs to support each resident in their choices of activities, leading to four residents not being offered meaningful activities of their choosing. Despite documented preferences for music and social activities, residents were not encouraged or assisted to participate in a live Elvis concert event.
The facility failed to assess residents for the risk of entrapment from bed rails, did not review the risks and benefits with residents or their representatives, and did not obtain informed consent prior to installation. This affected four residents, including one who was found with their arm wedged between the bed rail and mattress.
The facility failed to ensure proper labeling and storage of drugs and biologicals. An unlocked and unattended medication cart was observed multiple times on the second floor Ridge unit, and alcoholic beverages were improperly stored in the first floor medication room. Staff acknowledged the importance of locking medication carts and properly labeling alcohol, but these practices were not consistently followed.
The facility failed to maintain an effective pest control program, resulting in the presence of drain flies and fruit flies on the first and second floors. Observations included live and dead drain flies in the second-floor Ridge side spa room and live fruit flies in the first and second-floor kitchenettes. The pest control vendor's reports did not specify the areas checked, and staff were unclear about the reporting and treatment processes.
The facility failed to maintain a safe, clean, and homelike environment across three floors, with issues including unclean resident wheelchairs, damaged and sticky flooring, loud dining environments, and self-locking spa doors. Observations and interviews revealed gaps in cleaning, maintenance, and oversight, affecting residents' comfort and safety.
The facility failed to ensure residents received necessary assistance with activities of daily living, including showering, nail care, and toileting, leading to deficiencies in personal hygiene and dignity.
The facility failed to maintain an effective infection control program, with staff not adhering to hand hygiene and PPE protocols for residents on enhanced barrier and contact precautions. Multiple staff members, including CNAs, an LPN, and the Assistant Director of Nursing, did not follow proper procedures during medication administration, wound care, and incontinence care, leading to potential infection risks.
The facility failed to develop and implement a comprehensive care plan for a resident with an indwelling urinary catheter, despite physician orders and the resident's severe cognitive impairment and multiple pressure injuries. Observations and interviews indicated potential issues with catheter maintenance and documentation.
The facility failed to ensure that call systems were accessible for two residents, leading to potential safety risks. One resident with severe impairments was repeatedly observed with their call light out of reach, while another resident was left alone in the shower room without access to the call light.
The facility failed to ensure residents were treated with respect and dignity. A CNA publicly discussed a resident's urinary drainage device in the dining room, compromising the resident's privacy. Additionally, staff were observed using personal communication devices in care areas, violating facility policy and neglecting resident needs.
The facility failed to notify the health care proxy of a resident with Alzheimer's disease and urinary incontinence when new wounds requiring treatment were identified. Despite facility policy requiring family notification of changes in condition, there was no documented evidence that the health care proxies were informed of the new wounds and treatments on two separate occasions.
The facility failed to investigate alleged violations involving two residents. One resident had an unwitnessed fall that was not investigated, and another resident had injuries of unknown origin that were not thoroughly investigated. The facility's policies on Falls Management and Prevention and Incident Occurrence and Reporting were not followed, leading to deficiencies in the investigation process.
A resident with Alzheimer's and urinary incontinence developed moisture-associated skin damage due to inadequate incontinence care. Facility policies requiring frequent checking and changing of incontinence briefs were not consistently followed, leading to new skin damage. Staff interviews and observations confirmed the lack of regular care and timely reporting of skin issues.
The facility did not post the daily resident census and the total number and actual hours worked by licensed and unlicensed nursing staff per shift for 4 of 6 days reviewed. The Administrator was unaware of the requirement to include separate shifts and hours for licensed staff.
The facility failed to follow planned menus for two residents, resulting in missing food items on their meal trays. Despite having procedures in place for checking meal tickets and verifying food items, discrepancies were observed, and the Food Service Director acknowledged past resident complaints about missing food items.
The facility failed to serve food and drink at palatable, attractive, and safe temperatures for two lunch meals. Observations revealed that food items were served at temperatures below the facility's policy requirements, and residents had complained about cold food. The Food Service Director acknowledged the issue and noted that test trays and food audits were conducted, but the measures were not effectively implemented.
The facility failed to ensure food was stored, prepared, distributed, and served according to professional standards. Issues included missing grease traps, stained ceiling tiles, a hole with exposed wiring, disrepair in the freezer floor, and expired and undated food in both the main kitchen and a unit kitchenette.
Failure to Verify Thickened Liquids Before Serving
Penalty
Summary
The facility failed to keep a resident’s environment as free from accident hazards as possible when a resident with a physician order for pudding-thick liquids was served thin liquids at dinner. The resident had diagnoses including dementia and difficulty swallowing, was alert to person only, and had been admitted on comfort/end-of-life care with a pureed diet and pudding-thick liquids documented in the admission assessment, hospital discharge summary, and care plan. The incident occurred when the resident’s meal tray was not checked against the meal ticket before being served. The meal ticket for the resident’s meals documented a pureed diet with pudding liquids, but a CNA gave the resident thin liquids without verifying the consistency with the nurse or checking the task sheet. The CNA poured cranberry juice into a cup, placed a straw in it, and also provided thin water through a straw before the dinner meal. The LPN did not check the tray prior to it being served and did not notify the supervisor when the resident’s family member reported that thin liquids were on the tray. Staff statements indicated the LPN believed diet information could be confirmed by the physician order or meal ticket, but did not review the tray before it was passed and did not assess the resident after the family reported the issue. The CNA stated the meal ticket did not identify thickened liquids and acknowledged giving the resident thin liquids without checking consistency with the nurse or task sheet. The Medical Director stated staff were expected to follow dietary physician orders for resident safety and confirmed the CNA gave the resident thin fluids without verifying they could have them first.
Food Storage and Dish Sanitization Deficiencies
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices in the main kitchen. During observation, two pans of cooked meat in the walk-in cooler were partially covered with plastic wrap and were not labeled or dated, and several prepared food items in the walk-in dairy cooler were also not labeled or dated. Food Service Director #40 identified the items as possibly beef from the day before, tuna and egg salad, and ranch dressing, but stated they should have been labeled and dated and did not know why they were not. In dry storage, two dented cans were observed on the shelves, and Food Service Director #40 moved them to an unlabeled shelf in the middle of the room, stating the shelf had previously been labeled for dented cans but the sign was missing. During dishwashing observations, Food Service Worker #41 demonstrated testing the sanitizer strength at the 3-bay sink, but the test strip did not register sanitizer because the sanitizer bay had been filled with hot water instead of sanitizer solution. The worker stated this was how the bay had been filled previously and that breakfast dishes had already been washed in the sink. Un-sanitized pans and utensils were removed from the rack and rewashed after the issue was identified. Additional observations showed the dish machine temperatures were 158 degrees Fahrenheit for cleaning and 167 degrees Fahrenheit for sanitizing, while the required sanitizing temperature was greater than 180 degrees Fahrenheit. Food Service Workers #42 and #43 stated they did not know what the temperatures meant and had not been trained on that information. One worker began carrying bowls from the dish room for general use before the surveyor intervened. The meat walk-in cooler, dairy walk-in cooler, milk walk-in cooler, pantry dairy cooler, and two reach-in refrigerators near the meat cook area were also observed with dried food in the gaskets, food debris, and poor repair, and the Food Service Director stated they were usually cleaned every few weeks.
Failure to Provide Adequate ADL Assistance With Hygiene, Feeding, and Clothing
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), including grooming and personal hygiene, as required by its ADL Care policy and residents’ care plans. The policy, revised 06/2025, required morning and evening care based on residents’ assistance levels, including partial bathing, mouth care, hair combing, dressing, keeping fingernails and toenails clean and at appropriate length, ensuring females were free from facial hair unless they chose otherwise, providing meal setup and assistance as needed, and offering clothing choices or providing choices if residents were unable. Despite these requirements, surveyors identified multiple instances where residents did not receive the planned ADL support. One resident with kidney failure and atrial fibrillation, cognitively intact and requiring partial/moderate assistance with personal hygiene and total assistance for bathing, was observed repeatedly over several days with multiple patches of white and gray facial hair on the upper lip, chin, and neck, and with long fingernails containing dark brown debris under all five nails on the right hand. The resident stated they did not want hair on their face and reported that staff did not offer to shave them even after morning care. A CNA who regularly cared for this resident acknowledged noticing the facial hair but stated they were too busy to shave the resident and were unsure about trimming nails, though they could clean them. Nursing staff, including an LPN and the Assistant DON, confirmed that personal hygiene included shaving and nail care and should be completed daily by CNAs, with nurses responsible for trimming diabetic residents’ nails, but they either had not noticed or were unaware of the resident’s long, dirty fingernails. Another resident with dementia and depression, with severe cognitive impairment and requiring substantial to maximal assistance with eating, was care planned for maximum assistance with a mechanically soft diet. Observations during multiple noon meals showed the resident seated at a table, often asleep, with meal trays provided but with inconsistent and interrupted assistance from CNAs and an LPN. Staff would begin assisting, then leave to help other residents, and at times did not attempt to wake or encourage the resident to eat, resulting in significant portions of food and beverages remaining untouched before the resident was removed from the table. A third resident with dementia, depression, and anxiety, severely cognitively impaired and dependent on staff for most ADLs including dressing, was observed on multiple occasions wearing visibly soiled clothing with white and brown substances on the front of their pants and shirt. Staff interviews confirmed this resident was dependent on staff for care, including clothing changes when soiled, and that assigned staff were responsible for ensuring clothing was clean, while the unit manager and DON stated residents should not wear soiled clothing and expected staff to change visibly soiled garments.
Failure to Maintain Safe and Palatable Food Temperatures During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide food and beverages that were palatable, flavorful, and maintained at safe and appetizing temperatures, as required by facility policy and state regulation. The facility’s Food Palatability policy required hot foods to be served at no less than 135°F and cold foods at no higher than 40°F, with meals transported in heated/cooled carts and served in a manner that maintained temperature. During a lunch observation for one resident, food temperatures measured and verified by an LPN showed fried chicken at 107°F, matzo ball soup at 131°F, and beverages at 63°F. The fried chicken was described as bland, and the beverages tasted lukewarm. The LPN manager reported that the meal carts were intended to keep hot items hot and cold items cold, but staff had to search multiple carts for the correct trays and then wait for a nurse to verify tray accuracy, which affected how trays were served. On a separate date during breakfast service, surveyors observed a meal transport cart on the unit with a sign stating it should not be plugged in or turned on because a repair company had been notified, yet the cart was plugged in and used. Test trays taken from this broken cart and from a functioning cart for two hospitalized residents showed multiple items outside required temperature ranges: egg and cheese croissants at 95°F and 101.8°F, cottage cheese at approximately 68°F, milk between 55.4°F and 58.1°F, and oatmeal at 128°F. The egg and cheese croissants and pancakes were described as cold, with butter not melting on the pancakes, and the cottage cheese and milk tasted warm. A CNA stated they frequently received complaints about the food and often had to reheat it for residents. A food service worker and the food service director both confirmed that hot food should be at least 140°F and cold food below 40°F, and acknowledged that cottage cheese at around 68°F, milk near 58°F, and egg and cheese croissants in the 90–100°F range were not acceptable. The food service director also noted that two delivery carts were not working and that plugging in a cart marked not to be used could cause the cold side to heat up, especially if cart doors were left open.
Dementia Care Plans Lacked Individualized Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services for residents with dementia by not maintaining individualized, person-centered care plans that reflected their current needs and behaviors. The report states that the facility’s care plan policy required care plans to be tailored to the resident and updated quarterly, annually, and with changes in condition, and the dementia care policy required individualized care, baseline and ongoing behavior details, and non-pharmacological approaches consistent with the resident’s needs. For one resident with Alzheimer’s disease and post-traumatic stress disorder, the admission baseline care plan documented dementia with impaired decision-making and included only general interventions such as using simple language, brief statements, and offering simple choices. Although the resident was admitted from a memory care facility and was documented as oriented to self only, the record also showed multiple behavioral changes after admission, including following other residents into their rooms and yelling at them, resistive care, refusal of the walker and nighttime medications, undressing and remaining naked in the sitting room, yelling and becoming agitated and aggressive toward staff, paranoia that staff were poisoning them, spitting out nighttime medication, and continued yelling and refusal of night care. The psychiatric evaluation noted depression, anxiety, PTSD, and dementia, and stated to reinforce coping skills and non-pharmacologic interventions, but the care plan did not contain documented non-pharmacologic interventions, coping skills, or updated person-centered strategies to address the resident’s current behavioral symptoms. For another resident with dementia and major depressive disorder with severe psychiatric features, the comprehensive care plan identified cognitive deficits and psychotropic drug use, but no interventions were documented for either focus area. The resident’s assessment showed severely impaired cognition and use of antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. Progress notes described crying, physical aggression toward nursing staff, difficulty being redirected, needing staff monitoring all shift, getting up unassisted, pulling items from tables, and requiring constant redirection. During observation, the resident rejected an activity aide’s attempt to engage them with a puppy doll and was later placed in bed for a nap. Interviews with staff and the DON confirmed that residents with dementia and those receiving antipsychotics should have individualized care plans with specific interventions, and the RN unit manager confirmed that no interventions were documented under psychotropic medication or cognitive impairment for this resident.
Medication Storage and Narcotic Count Documentation Deficiencies
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles in multiple medication storage areas. During observation, the Terrace Ridge medication cart was found unlocked and unattended at the nurses’ station while residents were walking in and out of the area. In the Terrace Lane medication cart, an opened Lispro insulin pen was stored in a plastic bag with no opened date and an illegible handwritten resident name, and two bottles of Prevagen vitamins were present with no opened date and no expiration date. The nurse stated the insulin belonged to a resident and had been used, and that the vitamins were brought in by families but should have open and expiration dates. The Terrace Ridge cart also contained three unlabeled tubes of barrier cream in a drawer. An LPN stated the cream was used for most residents but not all and should be kept in the treatment cart, and another LPN stated the cart should not have been left unlocked because residents on the dementia unit wandered and could access medications if it was unlocked. In the second floor medication room, a box of six tubes of barrier cream was identified as a treatment and should have been stored in the treatment cart labeled with the resident’s name. The narcotic count sheets used for each shift medication reconciliation were not legible, with medication names and prescription numbers difficult to read. The DON stated nurses should audit carts daily, medications should have labels with open and expiration dates, carts should be locked when not in use, and narcotic reconciliation sheets should be legible.
Failure to Initiate and Coordinate Wound Care and Specialist Follow-Up for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for a resident admitted with significant wounds. The resident had diagnoses including gangrene of the right leg and peripheral vascular disease, and the hospital discharge summary documented gangrenous changes to the right foot, possible osteomyelitis, and a plan for follow-up at a wound clinic for hyperbaric oxygen therapy. The hospital discharge summary also included specific wound care orders for the right foot, including daily iodine skin prep, dry dressing, keeping the area dry, preventing secondary soft tissue infection, and offloading in a specialized shoe. On admission, the RN assessment noted a warm, swollen right fourth and fifth toe with a betadine dressing that was clean, dry, and intact, but did not document the type and characteristics of the wound, and there was no evidence that wound care orders for the right foot were entered upon admission. The facility’s own policies required that on admission a licensed nurse complete a skin assessment, obtain and implement wound treatment orders, and notify a wound consultant so the resident could be added to the wound roster and seen weekly. The Wound Care and Wound Rounds Protocol required a complete skin assessment with documentation of size, appearance, and stage, physician notification, and obtaining treatment orders for any open areas. Despite these requirements, the resident’s comprehensive care plan initially only identified risk for skin breakdown and later documented a wound infection and actual skin breakdown, but there were still no wound treatment orders in place for 27 days after admission. The wound care team was not triggered to see the resident because no wound orders had been entered, and the first documented wound care provider evaluation did not occur until nearly four weeks after admission, when a nurse practitioner noted pre-existing ulcers of the right toes and heel and that the resident would have benefited from hyperbaric oxygen therapy. Interviews with staff revealed confusion and conflicting understandings about responsibility for placing admission wound orders and the handling of an outside wound clinic appointment. The ADON and DON stated that wound care orders should be placed on admission or within 48 hours using hospital discharge or after-visit summaries, and that if orders were missing, the provider should be called. They also stated that residents were not required to see the facility wound provider before attending specialized wound appointments. However, the RN who completed the admission assessment stated they were not taught how to place orders and believed the unit manager was responsible, while the RN unit manager stated that the admitting RN was responsible for placing wound orders and that they did not check orders during the resident’s stay. Progress notes documented that the resident’s family had arranged a specialized wound clinic appointment recommended by the hospital, but the CNO directed staff not to allow the resident to leave and to cancel the appointment until the in-house wound care team evaluated the resident. The DON later confirmed that the CNO ordered the cancellation because the facility did not want to incur the cost unless the facility wound care team deemed it necessary. As a result, the resident had no wound care orders and no timely wound specialist assessment for 27 days after admission, despite documented wounds and hospital orders.
Unclean Terrace Unit With Urine Odor and Dirty Surfaces
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment on the Terrace memory care unit. Surveyors observed a strong, foul urine odor on multiple occasions in the unit, including the dining room area on the Ridge side and throughout the unit. On 03/09/2026, room T-22 had brown/orange streaks and sticky black spots on the floor and smelled of urine, and two dining room chairs had a red sticky substance on the side. A chair in the sitting area on the Ridge side was also observed to be dirty with a brown sticky substance on the back and arms. During interviews, a family member stated the unit had foul odors and their parent’s room was filthy at times. Housekeeper #10 stated they were responsible for cleaning the Terrace unit, including sweeping, mopping, dusting, vacuuming, and cleaning the dining room floors and chairs, and acknowledged the sticky substances on the chairs and the stained floor in room T-22. Housekeeping staff and nursing staff stated residents urinated on the carpet and that the unit often smelled of urine or old food. The Housekeeping Supervisor and Director of Environmental Services confirmed the Terrace unit had one day-shift housekeeper and that the unit should not have odors, while the RN Unit Manager stated they were responsible for reporting environmental issues and had left a voicemail about the floor in room T-22 because it did not look good.
Failure to Provide Resident-Preferred Activities
Penalty
Summary
The facility failed to provide ongoing programs to support each resident in their choice of activities for one resident who had dementia, Alzheimer’s disease, and major depressive disorder. The resident’s 06/17/2025 MDS documented severely impaired cognition, dependence for all ADLs, and preferences for listening to music and being around animals. The care plan documented that the resident participated in music, enjoyed holding baby dolls or stuffed animals, liked animal visits, and should be provided a program calendar to identify activities of interest. The resident’s quarterly progress note described them as alert and oriented to self only, pleasant, verbally nonsensical, and a passive participant in activities who sometimes held stuffed animals and baby dolls. Observations showed the resident seated without activities or staff interaction, reaching for wheelchair brakes or the lift pad, and sleeping while the television was on with no other activity occurring. The family member stated they did not think the resident participated in any activities and wished the resident had pet visits. The Activities Director and an activity aide stated the resident enjoyed music, hand massages, pet visits, and baby dolls, but were not sure how often the resident was involved in music activities; the aide also stated dementia unit behaviors and staffing issues sometimes interfered with activities.
Improper Garbage Disposal and Debris Around Trash Compactor
Penalty
Summary
The facility failed to ensure garbage and refuse were disposed of properly for one trash compactor area. The facility’s Garbage Removal Plan, dated 09/2025, stated that garbage bags would be removed from the kitchen to the dumpster area when full and at the end of the day, that bags would not be overfilled to prevent tearing or spills, and that dietary staff would clean garbage containers and surrounding areas while dietary managers monitored compliance. During an observation on 03/06/2026 at 08:14 AM, surveyors found food debris, food wrappers, milk cartons, used gloves, and dirty utensils strewn about on the ground near the food compactor area. During an interview later that day, the Food Service Director stated the area had food and debris because of snow and plowing, and stated there should not be debris on the ground because it attracted pests.
Failure to Provide Timely Podiatry Care for Diabetic Resident
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, diabetes, and peripheral vascular disease did not receive proper foot care and treatment in accordance with professional standards of practice. Despite repeated recommendations from a wound care provider and a vascular physician for routine podiatry care, there was no documented evidence that the resident received podiatry services for an eight-month period. The resident had ongoing issues with foot ulcers and required specialized nail care due to their diabetic status, but only received podiatry care after a significant lapse. The resident's care plan addressed wound care and assistance with hygiene but did not specifically address nail care or the need for podiatry services. The facility lacked a documented policy or procedure outlining how podiatry consults were to be obtained or who was responsible for scheduling them. Interviews with staff revealed that while there was an informal process in place, it was not documented, and there was confusion regarding responsibility for arranging podiatry appointments. The absence of a clear, documented process contributed to the failure to provide timely podiatry care, as evidenced by the lack of podiatry visits during the eight-month period despite ongoing recommendations and the resident's medical needs.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to ensure ongoing provision of programs to support each resident in their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Specifically, four residents were not offered meaningful activities of their choosing as care planned. The facility's policy documented that the activity department would provide an organized and ongoing program for the residents, meeting their interests and well-being. However, observations and interviews revealed that residents were not encouraged or assisted to participate in activities, and their participation was not adequately tracked or documented by the activity aides. Resident #41, diagnosed with Alzheimer's disease, major depressive disorder, and generalized anxiety disorder, was observed inside the unit during a live Elvis concert event that they would have enjoyed. The resident's care plan indicated a preference for music and social activities, yet they were not taken outside for the event. Similarly, Resident #109, with Parkinson's disease and Alzheimer's disease, was found seated in the television lounge during the same event. Despite their documented interest in music and outdoor activities, they were not encouraged or assisted to attend the concert. Resident #119, diagnosed with Parkinson's disease and neurocognitive disorder with Lewy bodies, was also not taken to the live music event despite their care plan indicating a preference for music and social activities. The activity staff did not document refusals or reasons for not attending the event. Interviews with the activity aides and the Director of Activities revealed that there was a lack of coordination and documentation regarding resident participation in activities. The staff acknowledged the importance of activities for residents' quality of life but cited limited staffing as a challenge in ensuring all residents could attend events of interest.
Failure to Assess and Obtain Consent for Bed Rail Installation
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from bed rails prior to their installation, did not review the risks and benefits of bed rails with the residents or their representatives, and did not obtain informed consent prior to the installation of bed rails for four residents. Specifically, Resident #109 had no documented evidence of a bed rail assessment, explanation of risks and benefits, or consent prior to bed rail installation. Additionally, the resident's enabler bar was not removed timely, resulting in the resident being found with their arm between the enabler bar and the mattress. Resident #59 had diagnoses including spinal stenosis and chronic pain, with severely impaired cognition and functional limitations. Despite being at high risk for falls, there was no documented evidence of a bed rail assessment, explanation of risks and benefits, or consent prior to bed rail installation. Observations confirmed the presence of bed rails, and staff interviews revealed that the enabler bars were not listed on the certified nurse aide assignment sheet. Resident #119, diagnosed with Parkinson's disease and Lewy body dementia, also had no documented evidence of a bed rail assessment, explanation of risks and benefits, or consent prior to bed rail installation. The resident had a history of falls and was observed with a bed rail and a bruise on their arm. Similarly, Resident #109, with diagnoses including Parkinson's disease and Alzheimer's disease, had no documented evidence of a bed rail assessment, explanation of risks and benefits, or consent prior to bed rail installation. The resident experienced an incident where they were found with their arm wedged between the bed rail and the mattress, despite a prior request for the removal of the enabler bar.
Medication and Alcohol Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with currently accepted professional principles. Specifically, the second floor Ridge medication cart was observed to be unlocked and unattended on multiple occasions. On 5/17/2024 at 8:38 AM, the cart was left unlocked and unattended for two minutes with no nurse in sight. Similar observations were made on 5/17/2024 at 2:48 PM and on 5/20/2024 at 8:35 AM. Licensed Practical Nurse #3 and Licensed Practical Nurse #8 both acknowledged that the medication carts should be locked when not in use to prevent unauthorized access, which could lead to harm or illness if medications were taken by unauthorized individuals. Licensed Practical Nurse Manager #1 confirmed the importance of keeping medication carts locked to ensure safety. Additionally, the first floor medication room was found to have three bottles of alcoholic beverages stored improperly in a brown paper box on the floor. One bottle was labeled with a resident's name but did not have a physician's order, while the other two bottles were unlabeled. Licensed Practical Nurse #24 and Licensed Practical Nurse Unit Manager #17 both stated that alcohol should be labeled with the resident's name and stored properly, similar to medications. The Assistant Director of Nursing confirmed that alcohol requires an order and should be labeled and locked in the medication room. These observations indicate a failure to adhere to the facility's policies on medication and alcohol storage, posing potential risks to resident safety.
Ineffective Pest Control Program
Penalty
Summary
The facility did not maintain an effective pest control program, resulting in the presence of drain flies and fruit flies on the first and second floors. Specifically, observations were made of live and dead drain flies in the second-floor Ridge side spa room and live fruit flies in the first and second-floor kitchenettes on multiple occasions. The Pest Sighting Service Report Log and the Pest Control Vendor Invoice documented no pests observed from 2/28/2024 to 4/24/2024, and did not specify the facility areas checked by the vendor. During interviews, the Director of Environmental Services stated that staff should report pest sightings to the housekeeping team lead or a supervisor, and that the pest control vendor had been conducting monthly inspections without identifying any pests. However, it was unclear if the second-floor Ridge spa room drain was included in the treated areas. The Food Service Director was unaware of any fruit flies in the kitchenettes and mentioned that the main kitchen used a separate pest control vendor. The drains in the facility kitchenettes received monthly treatments, which could also be done as needed.
Facility Fails to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility did not ensure a safe, clean, comfortable, and homelike environment for residents across three floors. On the Terrace floor unit, resident wheelchairs were observed to be unclean with dried food debris, and the flooring and countertops were damaged and sticky. The first floor unit had sticky floors in the dining room, and the second floor unit had a resident room with a damaged commode, a spa room with a water-damaged cabinet, and cigarettes and loose tobacco were found in the kitchenette. Additionally, the noise level in the second floor dining room was excessively loud during meal service, disrupting residents' dining experience. The spa access doors on all three floors self-locked from the inside when opened too hard, posing a potential safety risk for residents and staff. Observations revealed that the cleaning and maintenance of resident wheelchairs were not consistently performed, as evidenced by the unclean state of the wheelchairs used by two residents. Interviews with staff indicated that the responsibility for cleaning wheelchairs fell on the night shift, but there was uncertainty and inconsistency in the execution of this task. The Director of Environmental Services was unaware of the unclean wheelchairs, highlighting a gap in oversight and communication. The dining environment on the second floor was found to be loud and disruptive, with dietary aides clearing dishes in a manner that caused significant noise while residents were still eating. This was observed multiple times, and staff acknowledged the issue but cited time constraints and procedural requirements as reasons for the early clearing of tables. Additionally, the noise from meal carts and feeding machines further contributed to the loud environment, affecting residents' dining experience. The self-locking spa doors on all three floors were identified as a safety concern, with instances of residents being locked inside and staff struggling to unlock the doors. The Director of Environmental Services was unaware of this issue, indicating a lack of regular inspection and maintenance of these doors. The facility also had issues with cleanliness and maintenance in various areas. Sticky floors were observed in the dining rooms on the first and Terrace floors, and there were stained ceiling tiles in the Terrace dining room. The second floor had a resident room with a damaged commode, a spa room with a water-damaged cabinet, and a kitchenette with staff food bags containing loose tobacco and cigarettes. The Terrace floor unit had a spa room with missing floor tiles and a damaged countertop, a resident room with scraped floors, and a dining room cabinet with cracked drawers. Interviews with the Director of Environmental Services and housekeeping staff revealed that these issues were not consistently identified and reported, leading to delays in maintenance and repairs.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. Specifically, Resident #31 was not assisted with showering, washing their hair, and removing facial hair. Observations showed the resident with greasy hair and multiple white gray hairs on their chin on multiple occasions. Documentation revealed that the resident did not receive showers as scheduled, and staff interviews confirmed that care was not consistently provided or documented. Resident #95, who had severe cognitive impairment, was not assisted with nail care. Observations showed the resident with long, jagged fingernails and dark brown debris under the nails. Documentation indicated that the resident did not receive personal hygiene care on several days, and staff interviews confirmed that nail care was not provided as required. Resident #103, who had severe cognitive impairment and was frequently incontinent, was not assisted with toileting. Continuous observation showed the resident was not provided with toileting or incontinence care for over six hours. Documentation and staff interviews confirmed that the resident was not toileted every 2-4 hours as required, which is essential for preventing urinary tract infections and skin breakdown.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, leading to multiple instances of non-compliance with infection control protocols. Specifically, an LPN did not perform hand hygiene or wear gloves while administering medication via a gastrostomy tube to a resident on enhanced barrier precautions. The LPN acknowledged the lapse but believed that washing hands before and after the procedure was sufficient, which contradicted the facility's infection control standards. The Unit Manager and Assistant Director of Nursing confirmed that gloves should have been worn during the procedure to prevent the spread of germs. Another resident on contact precautions did not receive the required personal protective equipment (PPE) from staff members. An LPN and two CNAs entered the resident's room without wearing PPE or performing hand hygiene. The LPN was unaware of the contact precautions sign and did not follow proper infection control procedures while administering insulin. The Unit Manager and Assistant Director of Nursing emphasized the importance of wearing full PPE to prevent the spread of infection, and it was noted that staff should be updated on residents' conditions during morning reports. A third resident on enhanced barrier precautions did not receive appropriate care from staff members who failed to wear gowns and perform hand hygiene during wound and incontinence care. Multiple staff members, including CNAs, an LPN, and the Assistant Director of Nursing, did not adhere to the required infection control measures. The Infection Preventionist confirmed that enhanced barrier precautions required gown and glove use for residents with wounds or indwelling medical devices to prevent the transmission of infections. The lack of proper signage and adherence to protocols was identified as a significant issue in maintaining infection control standards.
Failure to Implement Comprehensive Care Plan for Resident with Urinary Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with an indwelling urinary catheter. The resident, who had severe cognitive impairment, a history of stroke with right side paralysis, and multiple unstageable pressure injuries, had a physician's order for a urinary catheter to prevent further skin maceration and facilitate healing. However, the comprehensive care plan did not include documentation of the use of the urinary catheter, and the resident care instructions (Kardex) also lacked information on the catheter's use and care. Observations revealed that the resident's urinary collection bag contained yellow urine with white sediment, indicating potential issues with catheter maintenance. Interviews with the Licensed Practical Nurse Manager confirmed that the catheter was necessary due to the resident's wounds and that there were orders for routine catheter flushes to maintain patency. The nurse manager expected staff to report any changes in urine output or characteristics and to ensure the catheter was changed as ordered. The absence of these details in the care plan and the lack of follow-up could increase the risk of infection for the resident.
Inaccessible Call Systems for Residents
Penalty
Summary
The facility did not ensure that resident call systems were accessible for two residents, leading to potential safety risks. Resident #15, who had severe cognitive and visual impairments and a history of falls, was repeatedly observed with their call light out of reach. On multiple occasions, the call light was either on the floor or placed in a location that the resident could not access, despite the care plan specifying that the call light should always be within easy reach. Certified Nurse Aide #23 confirmed that call lights should be within arm's reach to prevent residents from attempting to stand up unassisted and potentially falling. Resident #56, who had a left femur fracture, dementia, and anxiety, was left alone in the shower room without access to the call light. The resident was placed on a shower stretcher, and the call light was positioned out of reach. Certified Nurse Aide #27 left the resident alone to retrieve a nurse, during which time the resident was locked in the shower room. The aide admitted that they did not typically leave residents alone and acknowledged the risk of leaving a resident without access to a call light. Licensed Practical Nurse Unit Manager #1 emphasized that all residents should have access to a call light at all times, including in the bathroom and shower room, to prevent falls and ensure timely assistance.
Violation of Resident Dignity and Staff Use of Personal Devices
Penalty
Summary
The facility did not ensure residents were treated with respect and dignity in a manner that promoted the maintenance or enhancement of their quality of life. Specifically, a Certified Nurse Aide (CNA) was observed speaking loudly about a resident's urinary drainage device in the main dining room, which compromised the resident's privacy and dignity. The resident, who had severe cognitive impairment and an indwelling catheter, was publicly told by the CNA that they had just used a bedpan and had a catheter, in the presence of other residents. This was confirmed by the Registered Nurse Manager, who acknowledged that discussing such personal information in a public area was inappropriate and undignified. Attempts to interview the CNA were unsuccessful as the call was not answered. Additionally, multiple staff members were observed using their personal communication devices in resident care areas during working hours, which violated the facility's policy. During a resident meeting, several residents reported that staff frequently used cell phones and earbuds in care areas, making it difficult for residents to communicate with them. Observations confirmed that staff, including a Licensed Practical Nurse (LPN) and a CNA, were using their phones in resident care areas instead of attending to residents. The LPN Unit Manager and the Registered Nurse Manager both confirmed that the use of personal cell phones in care areas was against policy and could lead to neglect of resident needs and violations of privacy and confidentiality.
Failure to Notify Health Care Proxy of Significant Change in Condition
Penalty
Summary
The facility failed to notify the health care proxy of Resident #48 when there was a significant change in the resident's condition, specifically the development of new wounds requiring treatment. Resident #48, who had diagnoses including Alzheimer's disease and urinary incontinence, was documented to have severely impaired cognition and was dependent on staff for various activities of daily living. The facility's policy required that family members be notified of changes in condition, including skin breakdown and open areas, but this was not followed in the case of Resident #48. On 10/18/2023, the Assistant Director of Nursing identified new open areas on the resident's buttocks and recommended treatment with collagenase. However, there was no documented evidence that the resident's health care proxies were notified of these new wounds and the subsequent treatment. Additionally, during an observation on 5/20/2024, a new reddened area was noted on the resident's buttocks, and again, there was no documented evidence that the health care proxies were informed of this new wound. Interviews with the resident's health care proxy and facility staff confirmed that the family was not notified of the new wounds as required. The health care proxy stated they were not aware of the current wounds and had not been updated on the resident's condition outside of care plan meetings. Facility staff acknowledged that the family should have been notified and that it was important for the resident's quality of life and for obtaining permission for treatment.
Failure to Investigate Alleged Violations
Penalty
Summary
The facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for two residents. Specifically, one resident had an unwitnessed fall that was not investigated, and another resident had injuries of unknown origin that were not thoroughly investigated. The facility's policies on Falls Management and Prevention and Incident Occurrence and Reporting were not followed, leading to deficiencies in the investigation process. One resident, admitted with diagnoses including Parkinson's disease and neurocognitive disorder with Lewy bodies, experienced multiple falls. Despite documented falls and injuries, there was no evidence that the facility investigated how and when the resident sustained a fractured rib. The interdisciplinary team reviewed accident and incident reports, but the investigation into the rib fracture was incomplete, and the root cause was not determined. Another resident, admitted with Alzheimer's disease and a history of falls, was found face down with injuries. There was no documented evidence that the resident was assessed by a registered nurse after the fall, and an accident and incident report could not be located. The facility staff turnover and lack of proper documentation contributed to the failure to investigate the fall and injuries thoroughly.
Failure to Provide Adequate Incontinence Care
Penalty
Summary
The facility failed to ensure that Resident #48, who was at risk for pressure ulcers, received necessary treatment and services to prevent new ulcers from developing and to promote wound healing. The resident, diagnosed with Alzheimer's disease and urinary incontinence, developed moisture-associated skin damage on two occasions due to inadequate incontinence care. The facility's policies required frequent checking and changing of incontinence briefs, as well as regular skin assessments and documentation, but these were not consistently followed for Resident #48. Certified nurse aide documentation revealed that incontinence care was not provided on 11 of 16 dates in October 2023 and for 17 of 19 days in May 2024. Observations showed that the resident often remained in a medical positioning wheelchair for extended periods without being provided with incontinence care, leading to saturated briefs and soiled mechanical lift pads. A new reddened area was noted on the resident's buttocks, which was identified as moisture-associated skin damage by the Assistant Director of Nursing. Interviews with staff confirmed that incontinence care was crucial for preventing skin breakdown and maintaining dignity, but it was not consistently provided to Resident #48. The resident's representative also reported frequent observations of saturated incontinence briefs and incontinence odors. Despite the facility's policies and the resident's care plan, the lack of regular incontinence care and timely reporting of new skin issues contributed to the development of new skin damage for Resident #48.
Failure to Post Daily Resident Census and Nursing Staff Hours
Penalty
Summary
The facility failed to post the daily resident census and the total number and actual hours worked by licensed and unlicensed nursing staff per shift for 4 of 6 days reviewed during the recertification and abbreviated surveys. Specifically, the postings did not include the daily census and did not separate the hours worked by registered nurses, licensed practical nurses, and certified nurse aides. The Administrator was unaware of the requirement to include separate shifts and hours for licensed staff and acknowledged the importance of providing this information for transparency to residents and families.
Failure to Follow Planned Menus
Penalty
Summary
The facility did not ensure that planned menus were followed for two residents, resulting in discrepancies between the meal tickets and the actual food items delivered. Specifically, one resident's lunch tray was missing peppers, matzo ball soup, and gravy, while another resident's lunch tray was missing a pineapple cup. These discrepancies were identified during observations on two separate dates when the residents' meal trays were used for test trays, and new trays had to be ordered for the residents. The Food Service Director confirmed that there was a dedicated staff member responsible for checking meal tickets during the food plating process and that a nurse on the floor was supposed to verify the food items before serving the trays. Despite these procedures, the discrepancies occurred, and the Food Service Director acknowledged that there had been some resident complaints about missing food items in the past. However, they stated that there had been no recent complaints about this issue.
Food and Drink Not Served at Palatable Temperatures
Penalty
Summary
The facility did not ensure that food and drink were served at palatable, attractive, and safe temperatures for two lunch meals reviewed on 5/17/2024 and 5/20/2024. Specifically, during an observation on 5/17/2024, a resident's lunch meal tray was delivered with French fries at 91 degrees Fahrenheit, ground fried chicken at 106 degrees Fahrenheit, mixed vegetables at 106 degrees Fahrenheit, and apple juice at 61 degrees Fahrenheit. Similarly, on 5/20/2024, another resident's lunch meal tray was delivered with mashed potatoes at 117 degrees Fahrenheit, soup at 108 degrees Fahrenheit, beef stew at 106 degrees Fahrenheit, and cabbage at 90 degrees Fahrenheit. These temperatures were not in compliance with the facility's policy, which required hot food to be served at no less than 140 degrees Fahrenheit and cold food at no higher than 40 degrees Fahrenheit. During an interview, the Food Service Director acknowledged that the food temperatures recorded were not palatable and that residents had complained about cold food during resident council meetings. The Food Service Director also mentioned that the food service management team conducted test trays a couple of times a week and had completed three test trays and 14 food audits for April 2024. Staff were instructed to keep hot box doors closed and plugged in to maintain appropriate food temperatures, but these measures were not effectively implemented, leading to the deficiency.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen and one of the unit kitchenettes. In the main kitchen, the ventilation hood system was missing a grease trap, there were multiple stained ceiling tiles, a hole in one of the kitchen walls with exposed wiring, the meat side of the freezer floor was in disrepair, and there was expired and undated food. Specifically, the dairy side cooler had expired milk, the meat side cooler had undated bagels, and the meat side bread rack had expired and undated bread. Additionally, the Terrace unit kitchenette contained expired and undated food items, including a moldy bag of grapes and a staff lunch box. During an interview, the Food Service Director acknowledged awareness of some of the issues, such as the stained ceiling tiles and the missing grease trap, but could not verify if maintenance was informed. The Food Service Director also stated that the stock person responsible for checking milk expiration dates did not report the expired milk, and they were unsure how the expired bread items were present after a recent disposal for Passover. The Director emphasized the importance of maintaining the kitchen for the safety of residents and staff.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 213 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Syracuse
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nottingham R H C F | 1.9 mi | ★★★★★ | 7 | 0 |
| Bishop Rehabilitation And Nursing Center | 3.3 mi | ★★★★★ | 6 | 0 |
| Loretto Health And Rehabilitation Center | 3.4 mi | ★★★★★ | 20 | 0 |
| Central Park Rehabilitation And Nursing Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Iroquois Nursing Home Inc | 3.7 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.