Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oneida Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A provider failed to timely sign and date a federally mandated visit note for a resident with multiple comorbidities, and the note included a physical assessment and vitals that staff said were pulled from a later change-in-condition entry after the resident had already been sent to the hospital. The DON and Medical Director stated the EMR auto-populated vitals and that a mandatory visit note was not appropriate once the resident was no longer in the building, while the Administrator said the facility did not audit provider note timeliness.
A resident with severe cognitive impairment and serious medical conditions did not receive timely follow-up care with neurosurgery and pulmonology as required. The facility failed to schedule these appointments due to communication breakdowns and staff turnover, resulting in a deficiency in compliance with regulatory requirements.
The facility failed to uphold resident dignity, as evidenced by a resident not being addressed by their preferred name, another lacking a toothbrush for oral care, and two residents being transported backwards in wheelchairs. Staff acknowledged these actions as undignified, highlighting a need for improved adherence to care plans and resident rights.
A resident with severe cognitive impairment and a primary language other than English was not fully informed of their health status in a language they understood. Despite the facility's policy on translation services, no evidence of communication needs assessment or translation service provision was found. Observations showed the resident was not engaged in activities and did not understand staff communication attempts. Staff interviews confirmed the lack of appropriate communication tools, contributing to the resident's decline in psychosocial well-being.
The facility's 3rd Floor was found to have multiple deficiencies, including unclean floors and walls, damaged walls, and strong urine odors. Observations noted issues such as scrapes on railings and doors, lifting bathroom tiles, and unclean kitchenettes. Staff interviews revealed lapses in housekeeping and maintenance procedures, contributing to the failure to maintain a safe, clean, and homelike environment.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in meeting their medical and psychosocial needs. A resident was incorrectly care planned to receive a snack despite being NPO, another had an outdated transfer status and lacked fall mats, and a third lacked a care plan for antipsychotic medication and behavioral interventions. Staff interviews revealed communication gaps and inconsistencies in care delivery.
A resident with a left above-the-knee amputation and chronic obstructive pulmonary disease was found with long, unclean fingernails despite being cognitively intact and not rejecting care. Staff interviews revealed that personal hygiene, including nail care, was documented as completed, yet the resident did not receive the necessary assistance. The facility's policy required daily nail care, which was not followed, leading to the deficiency.
The facility failed to provide adequate activity programs for two residents, one with bipolar disorder and dementia, and another with altered mental status and malnutrition. The first resident was not invited to meaningful activities, while the second lacked in-room stimulation. Observations and interviews revealed inadequate staff engagement and scheduling issues, particularly on an isolated unit.
A resident with dysphagia and malnutrition did not receive the prescribed water flushes for their enteral feeding, and the feeding equipment was unlabeled. Observations showed discrepancies in the administration rate, and staff interviews revealed a lack of awareness and communication about the changes in settings, crucial for the resident's hydration. The facility's nursing staff failed to verify pump settings and report issues, leading to the deficiency.
A facility failed to conduct ongoing assessments and obtain informed consent before installing bed rails for a resident with acute dyskinesia and adult failure to thrive. Despite the facility's policy, the resident had bed rails without documented informed consent or a physician's order. Observations and staff interviews revealed inconsistencies in the assessment and documentation process, leading to a deficiency.
The facility's main kitchen had deficiencies in food storage and safety, including unclean surfaces and expired food items. Observations noted wet and slippery cooler floors, ice buildup in the freezer, and expired powdered sugar in storage. Interviews revealed lapses in cleaning and monitoring practices, contributing to these issues.
Provider Note Not Timely Signed or Matched to Resident Status
Penalty
Summary
The facility failed to ensure provider progress notes were written, signed, and dated at the required visit for one resident. Nurse Practitioner #4 completed a federally mandated visit and physical assessment for Resident #1, who had multiple comorbidities and was documented as stable with behaviors controlled. The provider note included assessment findings such as the resident sitting up in a chair, awake, pleasant, cooperative, with clear lungs, oxygen in use, palpable pulses, present bowel sounds, and no acute distress, but the note was not signed until several days later. The record also showed that Resident #1 had a change in condition with delirium behaviors and was sent to the hospital shortly after vitals were started. The provider note for the federally mandated visit contained the same vitals that were documented in the nursing change-in-condition note, and staff stated that if those vitals appeared in the provider note, the note must have been created after the resident had already gone to the hospital. The Medical Director stated that once the resident went to the hospital, a mandatory visit note would not be required based on federal requirements, and if addressed, it should only document that the resident went to the hospital and when, without a physical assessment. During interviews, the provider stated they did not see the resident on the later date reflected in the note and acknowledged they did not always sign visit notes the same day. The Administrator stated the facility did not audit the timeliness of provider documentation or note completion, and the DON stated the electronic system automatically pulled the most recent vitals into the provider note. The report cited 10 NYCRR 415.12(b)(2)(iii) for the failure to ensure provider documentation was complete, signed, and dated at the time of the visit.
Failure to Schedule Follow-Up Appointments for Resident
Penalty
Summary
The facility failed to provide necessary follow-up services for a resident who required specialized medical care. Resident #100, who had severe cognitive impairment and multiple serious medical conditions including pulmonary toxoplasmosis, acute respiratory failure, and cerebral edema, was referred to neurosurgery and pulmonology for further evaluation and care. Despite these referrals, the facility did not ensure that follow-up appointments were scheduled in a timely manner, as required by their policy. The resident's medical records indicated a need for urgent follow-up with neurosurgery and pulmonology after a hospital discharge, but there was no documented evidence that these appointments were scheduled. Interviews with staff revealed a lack of communication and coordination in scheduling these critical appointments. Medical Records Staff #16 was responsible for scheduling appointments but faced difficulties with the pulmonology office and was unaware of the neurosurgery referral. The Corporate Resource Nurse, acting as Unit Manager, was also unaware of the neurosurgery referral and the issues with scheduling the pulmonology appointment. The Director of Nursing stated that the facility's expectation was for outside consults to be followed up within the time frame directed by the consulting office. However, due to staff turnover and communication breakdowns, the necessary follow-up care for Resident #100 was not provided, leading to a deficiency in the facility's compliance with regulatory requirements.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to ensure a dignified existence for several residents, as evidenced by multiple observations and interviews. Resident #58, who had moderately impaired cognition, was not addressed by their preferred first name, contrary to their care plan. A certified nurse aide repeatedly called the resident by their last name from the doorway and loudly communicated the resident's personal information across the hall, which was acknowledged as inappropriate by both the aide and the acting unit manager. Resident #61, who required supervision for oral hygiene, was found without a toothbrush, preventing them from performing oral care. Despite the care plan indicating the need for assistance with daily living activities, the resident reported never having a toothbrush, and observations confirmed its absence. The acting unit manager noted the importance of oral care for dignity, acknowledging the oversight. Additionally, Residents #5 and #106 were observed being transported backwards in their wheelchairs, which was deemed undignified by the acting unit manager. This method of transport prevented the residents from seeing where they were going, further compromising their dignity and quality of life.
Failure to Provide Language-Appropriate Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure that a resident, whose primary language was not English, was fully informed of their health status and care in a language they understood. The resident, who had diagnoses including perforation of intestine, anemia, and hearing loss, was documented as having severely impaired cognitive skills and was rarely understood. Despite the facility's policy on translation services, there was no evidence that the resident was assessed for communication needs or that translation services were provided. The resident's care plan noted the need for an interpreter and communication tools, but these were not effectively utilized. Observations during the survey revealed that the resident was not engaged in activities and did not understand communication attempts made by staff using English, facial expressions, and hand gestures. The resident was observed in various settings, such as the dining room and during activities, where communication was attempted in English, which the resident did not comprehend. Staff interviews confirmed the lack of appropriate communication tools, such as audio books in the resident's language or a communication board, which was supposed to be available but was not found in the resident's room. The facility's failure to provide adequate communication support was further highlighted by staff interviews, where it was acknowledged that the resident's main recorded activity attendance was an error due to language barriers. The Activities Director and other staff members admitted to not having spoken to the resident's family to determine specific activities the resident would enjoy, and there was no documented evidence of efforts to engage the resident in a meaningful way. This lack of communication support and engagement contributed to the resident's decline in psychosocial well-being and adjustment to the nursing home placement.
Deficiencies in Cleanliness and Maintenance on 3rd Floor
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment on the 3rd Floor, as observed during the recertification survey. The deficiencies included multiple unclean floors and walls, damaged walls, and unpleasant odors. Specific observations noted a strong urine odor in various areas, including a resident's bathroom, the dining room, and the hallway near the dining room. Additionally, there were scrapes on the dining room railing and room doors, unclean floors, lifting bathroom tiles, and a sticky trap with unidentified bugs. The kitchenette was also found to be unclean. Interviews with staff revealed that the housekeeping and maintenance procedures were not effectively implemented. Housekeeper #27 mentioned that despite their efforts, the 3rd Floor consistently smelled like urine. Director of Maintenance #28 indicated that repairs were only made when reported, and they were unaware of the need for further repairs in certain areas. Director of Housekeeping #29 emphasized the importance of addressing odors and maintaining cleanliness for infection control, but it was evident that these standards were not consistently met, leading to the observed deficiencies.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in meeting their medical, nursing, and psychosocial needs. Resident #100, who had a physician order to receive nothing by mouth, was incorrectly care planned to be offered a bedtime snack. This discrepancy was noted in the care plan and the Kardex, leading to incorrect documentation by staff who mistakenly marked the snack as given. Resident #58, diagnosed with chronic viral hepatitis C and cerebral infarction, did not have an updated care plan reflecting their change in transfer status. The care plan initially required substantial assistance of two for transfers, but physical therapy later indicated the resident required stand-by assistance. Despite this, the care plan was not updated, and observations showed the resident without fall mats, which were part of their fall prevention plan. Staff interviews revealed a lack of clarity and communication regarding the resident's transfer needs and the absence of fall mats. Resident #101, with diagnoses including bipolar disorder and dementia, was on an antipsychotic medication but lacked a care plan addressing the medication and non-pharmacological interventions for aggression. The Treatment Administration Record documented the need to monitor behaviors and interventions, but there was no comprehensive care plan to guide staff. Interviews with staff highlighted the absence of a formal process for updating care plans and communicating changes, leading to inconsistencies in care delivery.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received necessary services to maintain personal hygiene. Specifically, Resident #86, who had a left above-the-knee amputation and chronic obstructive pulmonary disease, was observed with long, jagged fingernails containing black/brown debris. Despite being cognitively intact and not rejecting care, the resident reported that staff did not offer or assist with nail care, and they were unable to obtain nail clippers when requested. The resident's care plan required assistance with personal hygiene, including nail care, to prevent scratching and infection. Interviews with staff, including certified nurse aides and the Director of Nursing, revealed that personal hygiene care, including nail care, was documented as completed, yet the resident's nails remained unkempt. Staff acknowledged the importance of maintaining short and clean nails to prevent injury and infection. However, there was a lack of follow-through in providing the necessary nail care, as evidenced by the resident's repeated observations with unclean nails and their statements about not receiving assistance. The facility's policy required daily nail care as needed, but this was not adhered to, resulting in the deficiency.
Deficiency in Resident Activity Engagement
Penalty
Summary
The facility failed to ensure ongoing provision of programs to support each resident in their choices of activities, which are designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident. Specifically, two residents were affected by this deficiency. Resident #101, who has diagnoses including bipolar disorder, major depressive disorder, and unspecified dementia, was not invited to or assisted in attending activities that were meaningful to them and met their interests and preferences. Despite having a comprehensive care plan that included interventions to assist the resident in finding programs of interest and providing independent leisure supplies, the resident's activity log showed minimal participation in activities, and observations indicated a lack of engagement by the activities aide. Resident #100, with diagnoses including altered mental status, severe protein-calorie malnutrition, and cerebral edema, was not provided with in-room stimulation that met their interests and preferences. The resident's comprehensive care plan included interventions such as providing one-to-one bedside visits and diversional activities during periods of increased confusion or agitation. However, the activity logs indicated a high rate of refusal or unavailability for one-to-one visits, and observations showed the resident often left in their room without meaningful engagement or stimulation. Interviews with staff revealed issues with staffing and scheduling, particularly on the Third Floor unit, which was on isolation during the survey period. The activities director acknowledged the lack of structured activities on the unit and the reliance on a cart filled with various items for residents to choose from. The activities aides did not consistently invite residents to activities or provide appropriate engagement, leading to a deficiency in meeting the residents' activity needs.
Failure to Administer Enteral Feeding Correctly
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding was provided with the appropriate treatment and services to prevent complications. Specifically, Resident #100, who had diagnoses including unspecified protein-calorie malnutrition and dysphagia, did not receive the prescribed water flushes as ordered, and the tube feeding was observed to be unlabeled. The resident's care plan required tube feeding due to dysphagia, with specific instructions for administering Jevity 1.5 via PEG tube and auto flushes for hydration. Observations and record reviews revealed discrepancies in the administration of the tube feeding and water flushes. The Medication Administration Record (MAR) documented that the auto flush water was administered at a rate of 50 milliliters per hour, but observations showed it was set to 40 milliliters per hour. Additionally, the enteral tube feeding nutrition bottle and auto flush water bag were not labeled or dated. Interviews with staff, including a Registered Dietitian and Licensed Practical Nurses, indicated a lack of awareness and communication regarding the changes in the auto flush settings, which were crucial for the resident's hydration needs. The Director of Nursing and other staff members acknowledged the importance of ensuring the correct flow rate for enteral feedings to maintain proper hydration. However, the facility's nursing staff failed to verify the pump settings and did not report the discrepancies to the dietitian or medical team. This oversight in monitoring and administering the resident's enteral feeding regimen led to the deficiency identified during the survey.
Failure to Obtain Informed Consent and Conduct Ongoing Assessment for Bed Rails
Penalty
Summary
The facility failed to provide ongoing assessment and obtain informed consent before installing bed rails for Resident #68. The resident, who had diagnoses including acute dyskinesia and adult failure to thrive, was cognitively intact and required supervision for bed mobility. Despite the facility's policy requiring assessments and informed consent for side rail use, Resident #68 had bed rails installed without documented informed consent or a physician's order. Observations during the survey revealed that Resident #68 had brown half side rails on both sides of the bed, which were not documented as enabler bars in the care plan. Interviews with staff, including a Licensed Practical Nurse, Certified Nurse Aide, and Registered Nurse Unit Manager, indicated a lack of clarity and consistency in the assessment and documentation process for bed rails. The Unit Manager and Director of Nursing acknowledged the absence of a physician's order and informed consent for the bed rails, and the care plan did not reflect the use of full side rails as recommended in the previous assessment. The Director of Rehabilitation confirmed that therapy did not assess or recommend enabler bars for Resident #68, and nursing was responsible for ongoing assessments and care plan updates. The facility's failure to adhere to its policy and ensure proper documentation and consent for bed rail use resulted in a deficiency, as evidenced by the lack of informed consent and physician's order for Resident #68's bed rails.
Food Storage and Safety Deficiencies in Main Kitchen
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Observations revealed unclean surfaces and expired food items. Specifically, the fruit/cheese cooler floor was wet and slippery, and the freezer had small chunks of ice scattered on the floor, a large block of ice on the compressor, and icicles on the ceiling dripping water. Additionally, a brown sticky liquid was found on the floor at the entrance of the freezer, and expired powdered sugar was found in the dry storage room. Interviews with the Food Service Director and Kitchen Supervisor revealed that the kitchen was cleaned daily, but the freezer had not been defrosted in three months, leading to ice buildup. The staff was responsible for cleaning their areas, but short staffing sometimes prevented daily cleaning of the coolers and freezer. The freezer's ice buildup was attributed to a potentially improperly latched door, which could affect food temperatures. The dry food items were rotated a few times a week, but expired items were still found, indicating lapses in monitoring expiration dates.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Utica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Grand Rehabilitation And Nursing At Utica | 0.7 mi | ★★★★★ | 0 | 0 |
| The Pines At Utica Center For Nursing And Rehab | 0.7 mi | ★★★★★ | 1 | 0 |
| Mvhs Rehabilitation And Nursing Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Utica Rehabilitation & Nursing Center | 1.8 mi | ★★★★★ | 9 | 0 |
| Charles T Sitrin Health Care Center Inc | 2.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.