Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Northwoods Rehab And Nursing Center At Moravia during CMS and state inspections, most recent first.
RN coverage was not maintained for at least 8 consecutive hours a day, 7 days a week, and the facility had no waiver. The facility assessment listed staffing resources including a DON, ADON, IP, 2 RNs, 7 LPNs, and 15 CNAs, but timecards showed multiple days with no RN coverage. The DON said they were the only RN, had no one to cover when out, and were off on weekends; the Administrator said there was no RN Unit Manager and weekend RN coverage was inconsistent.
Unsecured and improperly labeled medications were found in multiple carts and the med room. The Side 1 and Side 2 med carts and a treatment cart were left unlocked and unattended, with the treatment cart containing scissors, medicated creams and shampoos, silver nitrate sticks, oxygen tubing, and razors. The Side 1 med cart also had eye drops and several inhalers that were not dated when opened, and the med room refrigerator had heavy ice buildup plus spills and a dirty towel inside.
The facility did not thoroughly investigate or report allegations of neglect related to medication errors for two residents, including missed doses of a controlled medication and IV antibiotics. Required documentation and state reporting were not completed, and discrepancies in medication administration records were not fully addressed.
Two residents experienced significant medication errors when a nurse falsely documented administering an antianxiety medication to one resident and failed to administer multiple doses of IV antibiotics to another. The errors were not properly documented or reported, and extra medication supplies matched the number of missed doses. Staff interviews confirmed that only RNs could administer IV antibiotics and that missed doses should be reported and documented, but this did not occur.
Unqualified Activities Director: The facility did not ensure the activities program was directed by a qualified professional. The Activities Director had only a HS diploma, no official recreational therapy background, and no required credential or experience documented for the role. They were responsible for the monthly calendar, resident activity planning, and the activities section of the MDS, but did not attend care plan meetings. The Administrator could not state what credentials qualified the person for the position.
A resident with MRSA, a Stage 4 pressure ulcer, and chronic foot ulcers did not receive wound care in line with the updated provider plan. The care plan omitted wounds on the right foot and right ankle, the updated order changes were not entered, weekly wound follow-up did not occur, and an LPN continued using older dressing treatments instead of the revised plan.
Failure to provide an ordered nutritional supplement was cited for a resident with protein-calorie malnutrition, poor appetite, and significant wt loss. The resident's care plan called for fortified foods and Magic Cups at lunch, but meal tickets showed the supplement while trays repeatedly did not include it. Staff reported the facility was out of Magic Cups and substituted applesauce, which the Dietary Director and RD stated was not nutritionally equivalent.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical needs. A resident with hemiplegia was not care planned for contractures, lacking necessary interventions like passive range of motion exercises. Two residents on anticoagulant therapy did not have care plans that included monitoring for side effects, compromising their safety. Staff interviews revealed gaps in communication and care plan updates.
A recertification survey revealed that a medication cart in the facility contained three types of medicated eye drops that were opened but not dated, contrary to professional standards. An LPN confirmed that medications should be labeled with the date opened, and the DON stated that undated medications should be discarded to prevent reduced efficacy.
The facility did not maintain food service safety standards, as observed during a survey. The main kitchen had unclean floors under the dish machine and in the walk-in cooler, with food debris and a brown liquid spill. Despite a checklist for daily cleaning and a quarterly deep cleaning schedule, these areas remained unclean. Interviews confirmed that daily cleaning was expected, but the cooler needed more attention. Mouse traps were also found on dry food storage shelves.
A resident with cognitive intactness and a need for assistance with personal hygiene was not provided with necessary grooming services, specifically shaving unwanted facial hair. Despite expressing a desire for assistance, staff failed to offer or provide the necessary supplies, resulting in the resident having thick facial hair. Interviews revealed a lack of communication and adherence to facility policy, which required daily personal hygiene tasks to be offered and refusals documented.
A facility failed to serve food at safe and appetizing temperatures, as observed during a survey. A resident reported dissatisfaction with the food's taste and temperature, and staff were unaware of the required temperature ranges. The acting Food Service Director was unsure about the policy for food palatability, contributing to the deficiency.
The facility did not post required daily nurse staffing information, including resident census and staff hours, in a publicly accessible area for four consecutive days. The Nurse Staff Scheduler and DON were unaware of the requirement to post this information, resulting in non-compliance during the recertification survey.
RN Coverage Not Maintained 7 Days a Week
Penalty
Summary
The facility did not ensure there were services of a Registered Nurse for at least eight consecutive hours, seven days a week, and it did not have a waiver. The facility assessment, revised 4/22/2025, documented 40 licensed beds and an average daily census of 35, and listed staffing resources that included 1 DON, 1 ADON, 1 Infection Preventionist, 2 RNs, 7 LPNs, and 15 CNAs. During the entrance conference, the Administrator stated there were no nursing staff waivers and that RN coverage was present when the DON was not in the building. Review of the September 2025 RN daily timecards showed no RN coverage on 9/6/2025, 9/14/2025, 9/15/2025 through 9/18/2025, and 9/21/2025. The DON stated they had been the only RN for the facility since 8/14/2025, were out from 9/15/2025 to 9/17/2025, and there was nobody to cover for them; they also stated they were off on weekends and thought RN #15 covered weekends. The Administrator stated there was no current RN Unit Manager, sometimes the RN MDS Coordinator picked up weekend supervision shifts, and RN #15 sometimes worked weekends but had not done so in a long time; they were not sure whether RN coverage was present when the DON was out sick.
Unsecured and Improperly Labeled Medications
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles in the facility’s Side 1 medication cart, Side 2 medication cart, medication room, and treatment cart. During the recertification survey, the Side 1 and Side 2 medication carts and the treatment cart were observed unlocked and unattended at multiple times, including while residents were sitting in the area. The treatment cart contained scissors, medicated shampoos and creams, silver nitrate sticks, ace wraps, oxygen tubing, and razors. Registered Nurse #17 stated the carts should always be locked when unattended to prevent access by residents, staff, or visitors. The Side 1 medication cart contained several medications that were not dated when opened, including artificial tears eye drops for one resident and multiple inhalers for several residents; one Ventolin inhaler had a dispense date of 3/26/2025. The medication room refrigerator was observed with significant ice buildup on the back, a discolored towel on the bottom shelf, and spilled white and brown substances on the bottom shelf. RN #17 stated they were unsure who monitored refrigerator temperatures or where they were documented, and the DON stated the refrigerator should be clean and free of ice buildup because it might affect medication temperatures. The facility policy stated medications and biologicals should be stored safely and securely, labeled appropriately, and expired medications removed from carts prior to or at expiration.
Failure to Investigate and Report Medication Error-Related Neglect
Penalty
Summary
Surveyors identified that the facility failed to thoroughly investigate and report allegations of neglect related to medication errors for two residents. The facility's policies required comprehensive investigation and reporting of incidents, including medication errors, to state and federal agencies. However, in both cases, the required steps were not followed, and there was no evidence that the incidents were reported to the New York State Department of Health as mandated. One resident with severe cognitive impairment and multiple psychiatric diagnoses did not receive a prescribed dose of clonazepam, despite documentation indicating it had been administered. The controlled drug record and pharmacy blister pack showed the medication was not removed or signed out on the date in question, and there was no progress note explaining the omission. The DON was informed of the discrepancy by staff, and the nurse involved was terminated, but there was no documentation of a thorough investigation or state reporting. Another resident, who had recently returned from the hospital with a peripherally inserted central catheter for IV antibiotics following a finger amputation due to infection, had multiple missed doses of ceftriaxone. The MAR showed several days where the antibiotic was not signed as administered, and the number of unused antibiotics matched the number of missed doses. The nurse responsible could not account for the missed administrations, and the DON noted irregularities in documentation. Despite the seriousness of the medication omissions, there was no evidence of a comprehensive investigation or required reporting to the Department of Health.
Significant Medication Errors Due to Nurse Actions and Documentation Failures
Penalty
Summary
Two residents experienced significant medication errors due to the actions and inactions of a registered nurse. One resident, with diagnoses including generalized anxiety disorder, dementia with behavioral disturbance, and major depressive disorder, was prescribed clonazepam for anxiety. The registered nurse documented administering the medication, but there was no evidence in the controlled substance drug log or blister pack that the medication was actually given, as the tablet count remained unchanged from the previous day. Another resident, who had osteomyelitis of the left hand and a partial finger amputation, was ordered to receive intravenous ceftriaxone daily. The medication administration record showed multiple missed doses on specific dates, with no documentation explaining the omissions. The registered nurse responsible for these administrations could not account for the extra antibiotic bags found in the medication room, which matched the number of unsigned doses, and was unable to provide a satisfactory explanation during interviews. Interviews with facility staff confirmed that only registered nurses were permitted to administer intravenous antibiotics, and that any missed doses should be reported and documented. The physician was not notified of the missed antibiotic doses, and there was no documentation in the medical record regarding the omissions. The facility's policy required all medication errors to be reported and investigated, but there was a lack of evidence that this process was followed in these cases.
Unqualified Activities Director
Penalty
Summary
The facility did not ensure that the activities program was directed by a qualified professional responsible for directing the development, implementation, supervision, and ongoing evaluation of the activities program. The report states that Director of Activities #9 was not qualified to direct activities for residents, and the facility’s job description required qualifications such as additional training in a related field, three years of experience in activities or group programming, and preferred supervisory experience. The survey report also documented that the Activities Director did not have the qualified professional credential and experience, including Therapeutic Recreation Specialist Certification, two years of age-appropriate experience within the last five years with one year full time in a patient activities program in a health care setting, or licensure as a Registered Occupational Therapist or Certified Occupational Therapy Assistant. During interview, the Activity Director stated they had been in the role since August 2025, had only a high school diploma, and had no official background in recreational therapy. They stated they were responsible for making the monthly calendar, planning events to engage residents socially, emotionally, physically, and spiritually, and completing the activities portion of the MDS, but did not attend resident care plan meetings. They also stated they had started employment as a cook about one year earlier, were promoted to Kitchen Director for 6 months, and then moved to Director of Activities. The Administrator stated the Activity Director had a background in social work and activities, but was unable to state what credentials qualified the person for the position.
Wound treatment changes not implemented and wound care follow-up not completed
Penalty
Summary
Resident #5 did not receive treatment and care in accordance with professional standards of practice for multiple wounds. The resident had diagnoses including MRSA infection, a Stage 4 pressure ulcer of the left heel, and non-pressure chronic ulcers of the left heel and midfoot. The 8/14/2025 MDS documented the resident was cognitively intact, had one unhealed Stage 4 pressure injury upon admission or reentry, two venous and atrial ulcers, and had dressings applied to the feet. Physician orders showed wound treatment changes for the right dorsum foot, left dorsum, right ankle, and soaking both feet in warm water and Epsom salts prior to dressing changes. The comprehensive care plan, revised 3/29/2025, addressed only an actual impairment to skin integrity of the left dorsal foot and included weekly treatment documentation, but it did not include the wounds to the right dorsal foot or the right ankle. A 9/4/2025 wound care telemedicine evaluation changed the treatment plan by discontinuing calcium alginate, adding leptospermum honey to the left dorsal foot and right dorsal foot wounds, and continuing xeroform to the right ankle, with weekly follow-up recommended. There was no documented evidence that the 9/4/2025 treatment plan was implemented, and there was no documented evidence the resident was evaluated weekly by the wound care provider after that visit. During observation on 9/24/2025, the resident was seen with feet soaking in a basin while the dressings remained on. The LPN stated the resident soaked their feet in Epsom salts for 20 minutes before dressing changes. The dressings on the bilateral feet were dated 9/22/2025, and the LPN removed the dressings and reapplied treatment using calcium alginate to the left foot and right foot, and xeroform to the right ankle, rather than the updated wound care plan. The DON stated the outside wound company saw residents virtually, that the resident had not been seen since 9/4/2025 because a provider was unavailable on 9/11/2025 and the DON was out sick the following week, and that the treatment changes had been reviewed but the orders were never updated. The Administrator stated the RN Unit Manager was responsible for reviewing wound notes and updating treatment orders, but there was no RN Unit Manager at the time.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
Provide enough food/fluids to maintain a resident's health was not ensured for Resident #31, who had diagnoses including protein-calorie malnutrition and vitamin D deficiency. The 6/9/2025 MDS documented moderately impaired cognition, poor appetite, partial/moderate assistance with eating, a weight of 119 pounds, and significant weight loss. The resident's weight record showed a decline from 135 pounds on 3/3/2025 to 115 pounds on 6/3/2025, with a repeated weight of 118.5 pounds and a 6.7% weight loss in one month. The 6/10/2025 RD progress note documented that Mighty Shake was discontinued and Magic Cups were to be trialed to prevent further weight loss. The 7/8/2025 care plan documented a nutrition problem and interventions that included super cereal and two Magic Cups at lunch. However, during observations on 9/22/2025, 9/23/2025, and 9/24/2025, the resident's meal tickets documented Magic Cup at lunch, but no Magic Cup was present on the meal trays. On one occasion, the resident attempted to drink applesauce, and on another stated they would eat ice cream if given it. Staff interviews showed confusion about responsibility for tray accuracy and supplement delivery. A CNA and an LPN stated the tray should be checked and that if Magic Cups were on the meal ticket, the resident should receive them. The DON and Dietary Director stated the facility was out of Magic Cups all week and substituted applesauce, and the Dietary Director stated applesauce was not nutritionally equivalent to Magic Cups or Mighty Shakes. The RD stated that when Magic Cups were recommended, the resident was expected to receive them, and that applesauce was not an acceptable substitute.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in addressing their medical needs. Resident #6, who was admitted with flaccid hemiplegia and Type 2 diabetes, was not care planned for contractures in their left hand. Despite observations of the resident's contracted hand and their inability to open it, the care plan lacked interventions such as passive range of motion exercises or the use of a palm guard or hand splint. Interviews with staff revealed a lack of awareness and documentation regarding the resident's contracture, indicating a failure to provide necessary therapeutic interventions. Resident #9, diagnosed with chronic obstructive pulmonary disease and atrial fibrillation, was receiving anticoagulant therapy but did not have a care plan that included interventions for monitoring anticoagulant therapy. The absence of such interventions in the care plan meant that staff were not informed about monitoring for potential side effects like bruising or bleeding, which are critical for residents on blood thinners. Interviews with nursing staff highlighted a gap in communication and updating of care plans, which could compromise the resident's safety. Similarly, Resident #13, who had chronic atrial fibrillation and was on anticoagulant medication, did not have a care plan documenting anticoagulation therapy. The care instructions also failed to include monitoring for signs of abnormal bleeding. The Assistant Director of Nursing initially believed the resident was not on anticoagulants, indicating a lack of accurate information and oversight in care planning. This oversight could lead to inadequate monitoring and response to potential complications from anticoagulant use.
Medication Labeling Deficiency Found in Facility
Penalty
Summary
During a recertification survey conducted from June 10 to June 13, 2024, it was found that the facility did not adhere to professional standards for labeling drugs and biologicals. Specifically, one of the two medication carts reviewed, referred to as Side 2, contained three types of medicated eye drops that were opened but not dated. The medications included erythromycin ophthalmic ointment, polyvinyl alcohol ophthalmic solution, and timolol maleate ophthalmic solution. The facility's policy on medication storage, which was undated, stated that medications should be stored in a manner that maintains their integrity and ensures resident safety, in accordance with Department of Health guidelines. During an observation on June 11, 2024, a Licensed Practical Nurse (LPN) confirmed that medications should be labeled with the date they are opened. The LPN stated that if an opened medication was not dated, it should be discarded and replaced, as eye drops are typically effective for 30 days once opened. The Director of Nursing (DON) also confirmed that opened medications should be dated with either the open date or the expiration date, and that undated medications should be discarded to prevent reduced efficacy and potential adverse effects.
Deficiency in Food Service Safety Standards
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. During the recertification survey, observations revealed that the floors under the dish machine and in the walk-in cooler were unclean with food debris, and there was a brown liquid spilled on the walk-in cooler floor. Despite a dietary checklist that required daily sweeping and mopping, and a quarterly deep cleaning schedule that included the dishwasher area and walk-in refrigerator, these areas remained unclean. Interviews with kitchen staff and the acting Food Service Director confirmed that daily cleaning was expected, but the cooler required more attention. Mouse traps were also observed on the dry food storage shelves, indicating further issues with maintaining sanitary conditions.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to ensure that a resident, who was unable to independently perform activities of daily living, received the necessary assistance with grooming and personal hygiene. Specifically, the resident, who was cognitively intact and required set-up or clean-up assistance with personal hygiene, was not assisted with shaving unwanted facial hair. Despite the resident expressing a desire to have their facial hair shaved or trimmed, staff did not provide a razor or offer assistance, resulting in the resident having thick, curly facial hair covering their chin, upper lip, and neck. Interviews with staff revealed a lack of communication and follow-through regarding the resident's personal hygiene needs. A certified nurse aide admitted to not offering or providing the necessary supplies for shaving, despite being aware of the resident's preferences. Additionally, the LPN and Assistant Director of Nursing acknowledged the importance of maintaining the resident's dignity through personal hygiene but failed to ensure that the resident's needs were met. The facility's policy required that personal hygiene tasks be offered and completed daily, with refusals documented and reported, but there was no record of refusals or progress notes for the resident in question.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at safe and appetizing temperatures. During the recertification and abbreviated surveys, it was observed that a lunch meal served on 6/11/2024 did not meet these standards. Specifically, the temperatures of the food items on the test tray were below the required levels, with a cheeseburger at 112 degrees Fahrenheit, carrots at 111 degrees Fahrenheit, milk at 55 degrees Fahrenheit, and pudding at 65 degrees Fahrenheit. These temperatures did not comply with the facility's policy, which mandates that hot food be kept at 135 degrees Fahrenheit or above and cold food at 41 degrees Fahrenheit or below. Interviews conducted during the survey revealed a lack of awareness among staff regarding the required temperature ranges for food. A resident expressed dissatisfaction with the taste and temperature of the food, stating that hot foods were not served hot enough and became cold before consumption. Additionally, the acting Food Service Director, who was also the Administrator, was unsure about the policy for food palatability and incorrectly stated that food should be served at 140 degrees Fahrenheit. This lack of knowledge and adherence to the facility's food temperature policy contributed to the deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, including the current resident census and the total number and actual hours worked by licensed and unlicensed nursing staff responsible for resident care per shift. This information was not posted in a prominent place readily accessible to residents and visitors for four consecutive days during the recertification survey conducted from June 10, 2024, to June 13, 2024. The facility lacked a policy on posting daily nurse staffing information, and observations confirmed the absence of this information in accessible areas on each day of the survey. Interviews with the Nurse Staff Scheduler/Charge Nurse and the Director of Nursing revealed a lack of awareness regarding the requirement to post this information daily in a public area. The Nurse Staff Scheduler/Charge Nurse, who was responsible for the nursing staff schedule, stated they were unaware of the posting requirement. Similarly, the Director of Nursing, who assisted with the staff schedule, acknowledged that while they kept a copy of the schedule, it was not posted in a publicly accessible location.
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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 Moravia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Groton Community Health Care Ctr Res Care Fac | 9.4 mi | ★★★★★ | 25 | 0 |
| Guthrie Cortland Medical Center | 14.1 mi | ★★★★★ | 14 | 2 |
| Cortland Park Rehabilitation And Nursing Center | 14.9 mi | ★★★★★ | 0 | 0 |
| Crown Park Rehabilitation And Nursing Center | 15.6 mi | ★★★★★ | 2 | 0 |
| Auburn Rehabilitation & Nursing Center | 15.9 mi | ★★★★★ | 0 | 0 |
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