Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Morningstar Residential Care Center during CMS and state inspections, most recent first.
A resident with a documented Full Code status on their MOLST form was found unresponsive, but staff did not initiate CPR due to reliance on incorrect DNR/DNI orders in the electronic medical record. Multiple LPNs failed to verify the resident's advance directive status with the resident, representative, or physician, and the physician signed the order without independent confirmation. This breakdown in documentation and communication led to the resident not receiving life-sustaining treatment as per their wishes.
A resident at risk for skin breakdown developed a new unstageable pressure ulcer on the heel that was identified by a CNA and reported to an LPN and RN supervisor, but the wound was not documented, assessed, or treated for approximately two weeks. The facility's policy requiring timely assessment, intervention, and documentation was not followed, resulting in a delay in care.
Two residents in the facility did not receive timely and appropriate care for pressure ulcers and nutritional needs. One resident developed new pressure ulcers, and treatment orders were not updated as recommended by the wound physician, leading to worsening of their condition and eventual hospitalization. Another resident developed a Stage 3 pressure ulcer and experienced significant weight loss, but the registered dietitian was not notified in a timely manner to reassess their nutritional needs.
A resident with dementia and a history of falls exhibited frequent exit-seeking behaviors, but the facility failed to include interventions in their care plan. Despite being identified as a moderate risk for wandering, the resident's care plan lacked measures to prevent elopement, leading to the resident exiting the building and being found in the parking lot. Staff were aware of the behaviors but did not implement specific interventions.
A resident with dementia and a history of exit-seeking behaviors left the facility unsupervised due to inadequate supervision and lack of a care plan addressing their wandering risk. Despite staff awareness of the resident's behaviors, there was no coordinated plan to manage the risk, and the resident exited through a side door, later found in the parking lot.
Failure to Verify and Communicate Advance Directives Results in Lack of CPR
Penalty
Summary
The facility failed to establish and implement consistent mechanisms for documenting and communicating a resident's choice regarding advance directives to the staff responsible for care. One resident, who had a Medical Orders for Life Sustaining Treatment (MOLST) form indicating Full Code status, was found without a pulse and respirations. Staff did not initiate cardiopulmonary resuscitation (CPR) as required by the resident's documented wishes. Instead, staff relied on incorrect advance directive information entered into the electronic medical record, which stated Do Not Resuscitate (DNR)/Do Not Intubate (DNI), and did not verify the resident's current wishes with the resident, their representative, or the MOLST form. The deficiency was compounded by a series of documentation and communication failures. Upon the resident's readmission from the hospital, an LPN entered a DNR/DNI order into the electronic medical record based on unverified information from another staff member, without consulting the resident, their representative, or the physician. Another LPN confirmed the order without independent verification. The physician subsequently signed the order remotely, relying on nursing staff to have completed the necessary checks. There was no evidence that the MOLST form or the resident's current wishes were reviewed or validated during this process. When the resident was found unresponsive, staff checked the electronic medical record rather than the MOLST form, resulting in no CPR being initiated despite the resident's Full Code status. The Director of Nursing later confirmed that the MOLST form indicated Full Code, but CPR was not performed due to signs of irreversible death. The facility's failure to verify and accurately document advance directives placed all residents with such directives at risk and resulted in actual harm to the resident involved.
Failure to Timely Assess and Treat New Pressure Ulcer
Penalty
Summary
A resident with diagnoses including heart failure and weakness, and who was assessed as being at risk for skin breakdown, developed a new unstageable pressure ulcer on the left heel. The wound was first observed by a certified nurse aide, who reported it to an LPN. The LPN then reported the wound to the registered nurse supervisor. Despite these notifications, there was no documentation of the wound, no assessment performed by licensed staff, and no treatment order was implemented at the time the wound was discovered. The facility's policy required timely and appropriate assessment, intervention, and documentation of skin issues, as well as prompt notification to the attending practitioner and other relevant healthcare professionals. However, after the wound was initially identified, there was a lapse of approximately two weeks during which the wound was neither assessed nor treated. Staff interviews confirmed that the wound was reported up the chain of command, but no further action was taken, and the wound was not documented in the resident's medical record. The LPN involved acknowledged that they did not document the wound and should have done so, while the registered nurse supervisor did not recall the incident and there was no evidence of their assessment or follow-up. It was only after the former Director of Nursing became aware of the wound that an investigation was initiated, the wound was assessed, and a treatment order was obtained. The delay in assessment and treatment was confirmed by staff statements and facility investigation, which concluded that the resident did not receive timely care for the pressure ulcer. The lack of documentation, assessment, and prompt intervention was inconsistent with professional standards of practice and the facility's own policies.
Failure to Provide Timely Pressure Ulcer Care and Nutritional Assessment
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers or at risk of developing them, as observed during the survey. Resident #1 developed new pressure ulcers, and there was no documented evidence that recommended treatment orders were obtained or implemented in a timely manner. Additionally, diagnostic tests were not ordered or obtained promptly. The resident's condition included dementia, and they required substantial assistance with mobility. Despite having a comprehensive care plan that included interventions for skin breakdown, the facility did not update treatment orders as recommended by the wound physician, leading to worsening of the resident's condition. Resident #1's treatment orders were not updated to reflect the wound physician's recommendations for the sacral ulcer and ischium ulcers. The facility continued to apply treatments that were not appropriate for the resident's current condition, and there was a lack of timely communication and implementation of the wound physician's orders. The resident's condition deteriorated, with the development of significant ulcers and signs of infection, which were not addressed adequately by the facility. The resident was eventually hospitalized and diagnosed with osteomyelitis and sepsis, and later expired. Resident #3 developed a Stage 3 pressure ulcer and experienced significant weight loss. However, there was no documented evidence that the registered dietitian reassessed the resident's nutritional needs in a timely manner. The resident's care plan included monitoring for skin breakdown and nutritional status, but the facility failed to notify the dietitian promptly about the resident's condition. The dietitian's assessment was delayed, and the resident's nutritional needs were not addressed in a timely manner, contributing to the deficiency.
Plan Of Correction
Plan of Correction: Approved February 3, 2025 1. Residents #1 and #3 are no longer residents of the facility. The nurse managers for residents #1 and #3 were provided written education for not following the facilities policy in regard to orders management/transcriptions and weight loss. The dietician was also provided written education on the facility weight loss and wound management policy. 2. A facility wide audit was completed on 12/20/2024 of all residents’ weights. Any identified weight loss was confirmed with a reweight and communicated via documentation in the resident records to the medical provider, dietitian, and then reviewed with MDS. There were no other residents identified with unaddressed weight loss, finding no other residents having been impacted by the deficient practice. 3. A facility wide audit was conducted on 12/06/2024 that included a head-to-toe skin check on all residents to identify skin issues that may have not been documented or with wound care orders. This includes an audit of all residents being followed by an outside wound care service, ensuring that all orders from the most recent visit were transcribed as written. The audit identified that no other residents were impacted. 4. The facility medical orders management policy (#6011) was reviewed, finding it to be appropriate and not followed by staff resulting in deficient practice. The facility weight policy (#8220) was reviewed, found to be appropriate and not followed by staff, resulting in the deficient practice. The skin management policy (#8162) was reviewed and revised to clarify nurse managers expectations of: - Following resident active wounds by documenting the results of the visit in the residents’ record and notifying the medical provider and dietitian. - The required immediate review of the outside wound consultants visits to include transcribing the consultant orders the same day as the visit. - Add a progress note acknowledging that they completed the transcriptions, documentation, and in house medical/dietitian notification of the visit. 5. Education has been given to the nurse managers and DON on medication orders management/transcriptions, consult visits, weight changes, and skin management policy updates. 6. The DON is completing weekly audits while holding a weekly skin and weight meeting with MDS, nurse managers, and the dietitian present. The audit includes: A. Keeping a running list of all active wounds in the facility on a spreadsheet B. Checking that all wound orders including consultant visits for the residents are present and correct weekly on the spreadsheet. C. Checks that the care plans are present and appropriate for all active wounds. D. Ensures dietitian and medical notifications are present in the record from the nurse managers. E. That the dietitian has completed a resident assessment within 72 hours of any new wounds or confirmed weight loss and that recommended supplements are ordered as found appropriate. 7. The deficiency will be brought to the next QAPI meeting and reviewed with the committee. The weekly audit results will also be brought to the monthly QAPI meeting until 90 days of 100% compliance is obtained. The weekly skin and weight meeting with the IDT will remain indefinitely as a new facility process to ensure continued compliance. 8. Weekly audit of all dietitian notes will be pulled and reviewed at the weekly wound and weight management meeting and brought to QA to ensure compliance that resident assessment was completed within 72 hours of any new wounds or confirmed weight loss. After 4 weeks we will move to monthly audits x 3 months. Then review with QAPI to determine the frequency going forward. 9. The DON/designee is responsible for the completion and compliance of this plan.
Failure to Address Exit-Seeking Behaviors in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who exhibited frequent exit-seeking behaviors. Despite the resident's history of dementia, psychotic disorder with delusions, and falls, the care plan did not include interventions to address these behaviors. The resident was able to exit the building and was found in the parking lot, indicating a lack of appropriate measures to prevent such incidents. The facility's policies required an individualized care plan based on assessments and diagnostic results, including a specific plan for residents at risk of elopement or wandering. However, the resident's care plan lacked documented interventions for wandering or exit-seeking behaviors from the time of admission until the incident occurred. The Wandering Risk Evaluation identified the resident as a moderate risk for wandering, but no interventions were documented in the care plan to mitigate this risk. Interviews with staff revealed that the resident frequently exhibited exit-seeking behaviors, such as attempting to leave the facility and verbalizing intentions to go to work or see family members. Staff were aware of these behaviors and discussed them during shift reports, but there was no clear plan or interventions in place to address the resident's wandering tendencies. The lack of a wander alert device and specific interventions contributed to the resident's ability to exit the facility, highlighting a deficiency in the care planning process.
Inadequate Supervision and Care Planning for Exit-Seeking Resident
Penalty
Summary
The facility failed to ensure adequate supervision and care planning for a resident who exhibited exit-seeking behaviors, leading to an incident where the resident exited the building unsupervised. The resident, diagnosed with dementia and a psychotic disorder, was assessed as having a moderate risk for wandering but did not have a care plan with interventions to address this risk. Despite frequent exit-seeking behaviors observed by staff, there was no documentation in the resident's care plan or progress notes addressing these behaviors. On the day of the incident, the resident was able to leave the facility through a side door, which triggered an alarm. Staff found the resident in the parking lot, confused and without their walker, believing they were going to their brother's vehicle. The resident was returned to the facility without injury. Staff statements indicated that the resident had been exit-seeking throughout the shift, but due to being occupied with other duties, the staff did not adequately monitor the resident's movements. Interviews revealed that there was no system in place on the unit to identify residents at risk of wandering or elopement, as the list was only kept at the reception desk. Staff were aware of the resident's behaviors but did not have a coordinated plan to manage the risk effectively. The resident's proximity to an emergency exit door was also noted as a potential factor in the ease of their elopement.
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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 Oswego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Luke Residential Health Care Facility Inc | 1.8 mi | ★★★★★ | 0 | 0 |
| Pontiac Nursing Home | 1.8 mi | ★★★★★ | 30 | 0 |
| Seneca Hill Manor Inc | 4.9 mi | ★★★★★ | 1 | 0 |
| Syracuse Home Association | 22.9 mi | ★★★★★ | 12 | 0 |
| The Cottages At Garden Grove, A Skilled Nrsg Comm | 26.5 mi | ★★★★★ | 4 | 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 August 2026) and official state health department websites.