Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Oneida Health Rehabilitation And Extended Care during CMS and state inspections, most recent first.
Improper hair restraints were observed in the main kitchen when four dietary aides prepared food and resident meal trays with long hair not fully restrained, including one aide with an unrestrained ponytail and others wearing only caps over shoulder-length hair. A resident later reported finding a hair in their pasta at lunch, and the FSD stated long hair covered only by a cap did not prevent hair from falling into food. Staff interviews showed inconsistent understanding of the hair restraint policy, including whether a hair net or cap was required for long hair.
A resident with acute respiratory failure, AFib, and hypertensive heart disease experienced tachycardia, with HR readings escalating despite medication, leading staff to contact the on‑call provider and transfer the resident to the hospital. Facility policy required notifying the resident and/or representative of transfers, including emergency transfers, and documenting the reason and notification in the record. Nursing notes documented the change in condition, provider contact, and transfer, but there was no documentation that the resident’s representative was notified. In interviews, an RN unit manager confirmed representatives should be notified the same day of a change in condition, and an RN involved in the transfer did not recall notifying the representative and believed a supervising RN would do so, acknowledging such notification should be charted.
A resident with right-sided paralysis, severely impaired cognition, and high fall risk was care planned to have a call light within reach and prompt staff response, but surveyors repeatedly observed the call light on the floor and out of reach while the resident was in bed. Staff, including a CNA, an LPN, and an RN manager, confirmed the resident was a fall risk and that all staff were responsible for ensuring call lights were accessible, yet they did not recall seeing the call light on the floor. This reflects a failure to follow the resident’s fall prevention care plan and maintain an environment free of accident hazards.
A resident with metabolic encephalopathy and diabetes had conflicting code status documentation: the eMOLST showed DNR while the EMR and care plan showed full code. Admission notes did not clearly document verification of the resident’s wishes, and staff used a red heart bracelet to indicate CPR status. Later, the MOLST was completed to reflect DNR after the resident’s preferences were clarified.
A resident with diabetes and atrial fibrillation received daily insulin injections and an anticoagulant, but the comprehensive care plan did not include the diabetes diagnosis, insulin administration, or anticoagulant use. Record review and staff interviews confirmed the care plan lacked guidance for monitoring blood sugar issues and anticoagulant-related bleeding or bruising, even though staff stated these items should have been included.
Two residents with gastrostomy tubes received enteral medications without physician orders specifying the amount of fluid to use for medication dilution. One LPN mixed crushed meds with tap water for one resident, while another LPN mixed crushed meds with ginger ale for a second resident despite no order for ginger ale. Staff stated the orders did not include the dilution amounts and that practices varied between nurses.
A resident with obesity, anemia, PVD, and high Braden risk developed worsening pressure injuries after the facility delayed wound orders, failed to document or follow ordered heel and buttock treatments, and did not consistently turn and reposition the resident. The resident’s Stage 2 buttock ulcers progressed to Stage 3 with drainage and odor, and the heel abrasion later became an unstageable PI. Staff observations and interviews showed missed heel floating, incomplete treatment documentation, and prolonged time in one position.
A resident with CHF, CKD, and acute cystitis was observed with an indwelling urinary catheter despite no documented physician order, indication, or care plan. The chart and staff interviews confirmed the catheter was present, but there were no orders for size, balloon size, reason for use, or catheter care instructions in the care plan or Kardex.
Failure to maintain nutritional status for a resident with dementia, chronic respiratory failure, and vascular disease. The resident had severe cognitive impairment, needed supervision for eating, and experienced ongoing significant wt loss over several months. Although a dietitian note identified significant wt loss and decreased intake, there was no documented comprehensive nutritional assessment or increased wt monitoring while the resident continued to decline, and staff reported the resident was on monthly weights unless nutrition requested closer monitoring.
A resident with chronic respiratory failure and a tracheostomy, who had a Full Code advance directive, was found unresponsive. Two LPNs failed to initiate a Code Blue or perform CPR, despite clear orders and policy, due to not properly checking for the code bracelet and assuming the resident was deceased. The RN Supervisor was notified but also did not immediately initiate resuscitation, leading to a significant delay before CPR was started. The resident was later pronounced deceased in the emergency department.
The facility failed to assist residents with activities of daily living, including grooming and toileting. One resident had unclean fingernails, another was not assisted out of bed for toileting, and a third was not toileted every 2 hours as care planned. Staff interviews confirmed these deficiencies.
The facility did not ensure sufficient nursing staff, leading to deficiencies in resident care, including delayed call bell responses, cold meals, and inadequate assistance with activities of daily living. Residents reported dissatisfaction, and staff confirmed the challenges in providing timely care due to staffing shortages.
The facility failed to maintain an effective infection prevention and control program. A resident with COVID-19 did not have proper transmission-based precautions, and two residents with indwelling medical devices were not placed on enhanced barrier precautions. Additionally, an LPN did not perform hand hygiene between residents during medication administration.
The facility failed to maintain an effective pest control program, resulting in fruit flies in the main kitchen and drain flies in the 2nd, 3rd, and 4th floor tub rooms. Observations revealed multiple live and dead flies, and the Environmental Services Manager was unaware of the pest issues in the tub rooms.
The facility failed to maintain the privacy and confidentiality of residents' medical records by leaving electronic medication administration records open and visible on an unattended medication cart in the hallway. An LPN was observed leaving the cart unattended multiple times, displaying residents' photographs and health information to passersby.
The facility failed to develop and implement comprehensive care plans for five residents, omitting critical information such as the use of video monitoring devices, anticoagulants, insulin, and antipsychotics, which are essential for ensuring proper care and monitoring.
The facility failed to provide meaningful activities that met the interests and preferences of two residents. One resident, with vision impairments and difficulty walking, could not attend music activities due to insufficient staff assistance. Another resident, with cognitive and physical limitations, did not leave the unit for activities due to a lack of staff for transfers. Both residents' activity preferences were not adequately supported, and there was insufficient documentation of activity refusals.
A resident admitted with congestive heart failure did not receive the prescribed diuretic medication for five days and was not monitored for weight changes as recommended. The facility's process for entering and checking new admission medications failed, leading to the omission of critical treatment and monitoring instructions.
A resident with sleep apnea received CPAP therapy without a plan for regular cleaning of the equipment, contrary to the facility's policy and professional standards. Staff interviews confirmed the absence of cleaning instructions in the care plan and treatment records, posing a risk of bacterial buildup and infection.
The facility failed to ensure residents were free from significant medication errors. One resident did not receive sacubitril-valsartan for heart failure, and another did not receive multiple medications, including brimonidine tartrate eye drops, ammonium lactate lotion, docusate sodium, and Juven. The LPN incorrectly documented these medications as administered, and there was no evidence of proper communication or documentation regarding the missed doses.
The facility failed to assist a resident with quadriplegia and respiratory failure in obtaining dental care despite complaints of tooth pain. The resident had not seen a dentist since admission, and there was no documentation of dental concerns or a consult in their medical record.
The facility failed to ensure food and drink were served at palatable temperatures. Observations during a survey revealed that cold food items were served above the required temperature, and residents reported receiving cold meals due to delays in meal tray distribution. Staff confirmed that the speed of distribution depended on the number of available staff.
The facility failed to ensure proper food storage, preparation, and cleanliness in the main kitchen. Observations revealed stained and sticky floors in the dairy walk-in cooler, food debris under cooler shelves, and improperly stacked pans on the clean drying rack. The Food Service Director confirmed these issues and acknowledged lapses in immediate cleaning and documentation.
A resident with multiple pressure ulcers did not receive necessary treatment and services, including a specialty mattress that was not checked for function for 14 days. The mattress pump was found broken and not operational, leading to further deterioration of the resident's condition. Staff failed to report the broken pump for repair, and the resident's care plan was not adequately followed.
The facility failed to provide a Medicare beneficiary with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 after discontinuation of Medicare Part A services. The resident, who had severe cognitive impairment and multiple diagnoses, did not receive the notice and remained in the facility beyond the end of Medicare coverage. Staff interviews revealed miscommunication regarding the responsibility for issuing the notice.
Improper Hair Restraints in Kitchen
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards because four dietary aides had improper hair restraints while working in the main kitchen. During the recertification survey on 01/20/2026, Dietary Aide #14 was observed walking through food preparation areas with an unrestrained long ponytail. Dietary Aides #15, #16, and #17 were observed preparing food and lunch trays while wearing only caps, with long shoulder-length hair untied or not fully restrained. The facility policy, revised 05/2023, stated employees would wear hair restraints and men with beards and/or mustaches would wear beard restraints. During interviews, Resident #13 stated they found a hair in their pasta at lunch that day and said it ruined their appetite. The Food Service Director stated staff needed to wear a hair net or a hat and that when long hair was only covered with a cap, it did not prevent hair from falling into food. Dietary Aide #18 stated the policy was to contain hair in a hair net or wear a baseball cap, and that either could be worn when food was present regardless of hair length. Dietary Aide #15 stated the policy required a hair net for longer hair and a cap only with short hair, and that their long hair not being completely restrained was an oversight because they were trying to hurry to work. Later, the Food Service Director stated hair needed to be fully restrained in the main kitchen.
Failure to Notify Resident Representative of Hospital Transfer After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s designated representative of a transfer to the hospital following a change in condition. Facility policy dated 09/16/2016 required that proper notification of a transfer or discharge be made to the resident and/or representative, including the reason for the transfer, with documentation in the clinical record, and that in an emergency transfer the representative receive written notice within 24 hours. The resident involved had diagnoses including acute respiratory failure with hypoxia, atrial fibrillation, and hypertensive heart disease with heart failure, and physician orders dated 04/11/2025 included monitoring vital signs every shift, metoprolol tartrate for hypertension and heart failure, and lorazepam as needed for anxiety. On 04/12/2025, nursing documentation showed the resident’s pulse was initially 101 and irregular, then later increased to 153, prompting notification of the RN Nursing Supervisor and administration of metoprolol. When the heart rate remained elevated at 140, lorazepam was given, and the on‑call medical provider was contacted. The provider instructed staff to send the resident to the hospital, and the RN Nursing Supervisor documented that the resident was transported to the emergency room for tachycardia. There was no documentation that the resident’s designated representative was notified of the transfer. In interviews, the RN Unit Manager stated representatives should be notified the day a change in condition occurs but was unsure if this resident’s representative had been notified, and the RN who arranged the transfer recalled sending the resident out and speaking with the provider but did not recall speaking with the representative, stating they believed the RN Nursing Supervisor would notify the representative and that such notification should be documented in the chart.
Failure to Maintain Call Light Within Reach for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at high risk for falls had their call light within reach as care planned, resulting in an environment that was not as free of accident hazards as possible. The resident had right-sided paralysis and weakness, severely impaired cognition, and required dependence for dressing, personal hygiene, and bed mobility. The resident’s comprehensive care plan, initiated due to high fall risk related to deconditioning, included interventions such as ensuring the call light was within reach, encouraging use of the call light for assistance, and prompt staff response. A fall risk assessment also documented the resident as a fall risk, with intermittent confusion, chairbound status, and incontinence. Despite these documented interventions, surveyors repeatedly observed the resident lying in bed with the call light on the floor under the top part of the bed and not within reach on multiple dates and times. Staff interviews confirmed that the resident was care planned for falls and that all staff were responsible for ensuring call lights were within reach. A CNA who cared for the resident during the survey week acknowledged the resident was care planned for falls and stated the call light should always be within reach, suggesting a clip could be used to prevent it from falling. An LPN and an RN manager both confirmed the resident was a fall risk with care plan interventions that included having the call light within reach and that all staff entering the room were responsible for ensuring this, but they did not recall seeing the call light on the floor. These observations and statements demonstrate that the care-planned intervention to keep the call light within reach was not consistently implemented.
Advance directive wishes were not consistently documented or communicated
Penalty
Summary
The facility failed to establish mechanisms for documenting and communicating a resident’s advance directive choices to staff responsible for care. For one resident with diagnoses including metabolic encephalopathy and diabetes, the electronic MOLST documented do not resuscitate/allow natural death, while the electronic medical record documented full code and an order to attempt CPR. The resident’s MDS assessment documented moderately impaired cognition, and the resident had previously been DNR during an earlier stay before being discharged and later readmitted. During the admission process, the physician documented that the resident wanted to be full code, but also noted there was a prior MOLST documenting DNR and that the resident would remain full code until the matter could be reassessed. The care plan was revised to reflect full code status with CPR interventions, yet the record contained no documentation of the resident’s advance directive wishes or verification of those wishes in the admission progress note or social work note. The resident’s MOLST was not completed at that time, despite the conflicting information in the chart. Later, the resident was observed wearing a red heart bracelet, and the resident stated they did not know what it was for. Staff stated the bracelet indicated a resident wanted CPR and that they would start CPR on an unresponsive resident wearing it. The RN manager stated that if a resident had a preexisting MOLST and preferences had not changed, a new MOLST did not need to be generated, but if preferences changed then a new one should be generated. The physician stated the resident had verbalized a preference contrary to the current MOLST and therefore it was not signed until clarification was obtained. The final MOLST later documented the resident verbally consented to do not attempt resuscitation, and the physician signed it.
Incomplete Care Plan for Diabetes and Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #144 that included the resident’s diabetes, insulin use, and anticoagulant use. The resident had diagnoses of diabetes and atrial fibrillation, and the 01/02/2026 MDS documented that the resident was cognitively intact, received daily insulin injections, and was on an anticoagulant. Physician orders dated 12/26/2025 included Lantus 5 units subcutaneously once daily for diabetes, insulin lispro 5 units subcutaneously before meals for diabetes, and apixaban 5 mg by mouth twice a day for atrial fibrillation. Record review found no documented evidence of a person-centered comprehensive care plan that addressed diabetes management, insulin administration, monitoring for hyperglycemia or hypoglycemia, or the use of an anticoagulant and monitoring for symptoms and side effects of anticoagulant use. During interviews, an LPN stated insulin and anticoagulants should be included in the care plan so staff would know to monitor for bleeding, bruising, and signs of hypoglycemia. An RN manager stated care plans were initiated by an RN and reviewed quarterly and as needed, and acknowledged the resident’s care plan did not include insulin or anticoagulant use even though it should have so staff would know to monitor for bleeding or bruising and for signs of hypoglycemia or hyperglycemia.
Enteral Medication Administration Without Ordered Dilution Instructions
Penalty
Summary
The facility failed to ensure enteral medications were administered in accordance with accepted professional standards and the prescriber’s orders for two residents with gastrostomy tubes. For both residents, the physician orders included tube feeding and water flush instructions, but did not specify the amount of fluid to be used when medications were crushed and instilled through the feeding tube. The medication administration records also did not include how much water was to be used to mix the tablet medications for tube administration. Resident #39 had diagnoses including gastrostomy tube and cerebral palsy, with severely impaired cognition and dependence on tube feeding for a substantial portion of calories and fluids. The resident’s orders directed flushes before and after medications and every 6 hours, but did not state the amount of water to dilute medications. During observation, an LPN crushed Reglan, mixed it with 60 milliliters of tap water, and administered it through the gastrostomy tube. The nurse stated there was no order for how much water to use with medication dilution and that the amount could vary from nurse to nurse. Resident #1 had diagnoses including gastrostomy tube and persistent vegetative state, with severely impaired cognition and total dependence on staff for tube feedings and flushes. The resident’s orders included bolus feeds, scheduled water flushes, and 30 milliliters before and after each medication pass and bolus feed, but did not specify the amount of fluid to mix with medications. During observation, an LPN stated crushed medications were mixed together with 120 milliliters of ginger ale, despite no physician order for ginger ale with medication administration. Staff interviews confirmed that the amount and type of fluid used to dilute medications were not specified in the orders and that nurses used varying amounts and fluids when administering enteral medications.
Delayed wound treatment and missed repositioning for resident with pressure injuries
Penalty
Summary
The facility failed to ensure a resident with multiple pressure injuries received timely treatment and services consistent with professional standards of practice. Resident #76 had diagnoses including obesity, anemia, and peripheral vascular disease, was cognitively intact, required maximum assistance for bed mobility, and was assessed as high risk for pressure injuries on the Braden scale. On admission, the resident had an abrasion to the right heel and later was documented with Stage 2 pressure ulcers on both buttocks. The facility’s care plan included weekly skin inspections, a flat bed, following skin breakdown protocols, and turning and positioning every two hours, but the record showed delays and omissions in implementing wound-related interventions. The buttock pressure ulcers were identified on 12/16/2025, but there was no treatment order or further documentation for the Stage 2 ulcers until 12/24/2025. At that time, the wounds had enlarged, and subsequent wound rounds documented continued progression in size. Orders later changed from cleansing and A&D ointment to Puracol powder, and then to Mupirocin with Optifoam after the wounds were found to have progressed to Stage 3 with copious drainage. A later wound clinic consult documented the buttock wounds were excoriated, foul smelling, and had purulent drainage, with orders for daily dressing changes, turning and repositioning every two hours, and limiting time on the resident’s bottom. The right heel abrasion identified on admission was not documented as being monitored before it was later found to be an unstageable pressure ulcer with dry dead tissue. Although orders were written for skin prep to both heels and for heels to be floated while in bed, there was no documented evidence that heel floating was added to the care plan or Kardex. The treatment administration record also showed missing documentation for ordered care, and during observation the resident’s heels were resting directly on the bed. During another observation, the resident was not turned and repositioned for several hours, and staff stated the resident should have been turned every two hours and the heels floated. Staff interviews also reflected that the buttock wounds should have had care plans, treatment, and provider notification in place earlier, and that the heel should have been monitored weekly.
Unordered urinary catheter without documented indication or care plan
Penalty
Summary
An indwelling urinary catheter was used for Resident #18 without a documented physician order, indication, or care plan. Resident #18 had diagnoses including congestive heart failure, chronic kidney disease, and acute cystitis, and the 12/05/2025 MDS documented severely impaired cognition, maximum/dependent assistance for all activities of daily living and transfers, and no indwelling catheter. The resident was observed with a urinary catheter on 01/20/2026 and 01/21/2026, while the unsigned 01/16/2026 admission assessment documented no indwelling urinary catheter. The record contained no physician admission order for the catheter, including size, care, or rationale for use, and there was no documented urinary catheter care plan or Kardex instructions. A 01/19/2026 physician progress note stated the resident had a new urinary catheter placed while in the hospital. During interviews, CNA #6 stated catheter care should be on the Kardex, LPN #7 stated catheters should be in the care plan and Kardex and confirmed there were no physician orders, and RN #8 stated catheter orders should include size, balloon size, and reason for use, with catheter care included in the care plan and Kardex.
Failure to Maintain Nutritional Status
Penalty
Summary
The facility failed to ensure acceptable nutritional status for one resident who had dementia, chronic respiratory failure, and vascular disease. The resident had severe cognitive impairment, symptoms of social isolation and depression, required supervision for eating, and showed a pattern of progressive weight loss over several months, including a 7.7% loss in 3 months, an 11% loss in 6 months, and a 12.2% loss in 6 months by the end of the review period. The resident’s care plan identified potential for altered nutritional status due to diagnoses and poor intake, and a dietitian note documented significant weight loss with decreased intake, unintended weight loss related to dementia and decreased intake, and updated food preferences and supplements. However, after the resident continued to lose weight, there was no documented evidence of a comprehensive nutritional assessment and no more frequent weights after the significant weight loss was identified in September, despite continued decline in weight through November, December, and January. Survey observations and interviews showed the resident was still eating poorly and needed assistance and supervision at meals. Staff stated weights were entered by nursing, reviewed for reweights and weekly weights, and that residents were usually on monthly weights unless nutrition requested closer monitoring. The dietitian and nursing staff also stated they were unaware of the resident’s ongoing weight loss until the later weight change was identified, and the resident had no new interventions in place between the September nutrition note and the later January weight loss review.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when facility staff failed to honor a resident's advance directive for resuscitation. The resident, who had chronic respiratory failure, a tracheostomy, and was designated as Full Code, was found unresponsive by staff. Despite clear physician orders and care plan documentation indicating the resident's wish for full resuscitative measures, the nurses present did not initiate a Code Blue or begin CPR as required by facility policy and the resident's advance directive. The two LPNs involved assessed the resident and determined the individual was deceased without verifying the presence of the required code bracelet on both arms, as per facility protocol. One LPN only checked one arm for the bracelet and, not seeing it, did not proceed with resuscitation. Both LPNs left the room and notified the RN Supervisor that the resident had expired, but did not call a Code Blue or attempt CPR. The RN Supervisor, upon being notified, prioritized another Code Blue on a different unit, assuming the unresponsive resident had a DNR order due to the lack of an emergent call and absence of a Code Blue being called. It was only after the RN Supervisor returned to the unit and confirmed the resident's Full Code status that a Code Blue was called and CPR was initiated, but this was significantly delayed. The resident was subsequently transported to the emergency department, where resuscitation efforts continued unsuccessfully and the resident was pronounced deceased. Interviews with staff revealed lapses in judgment and failure to follow established protocols for responding to unresponsive residents with Full Code status.
Removal Plan
- Licensed Practical Nurse #1 and Licensed Practical Nurse #2 were suspended immediately following the incident.
- Facility policies for Basic Life Support and Cardiopulmonary Resuscitation, Code Blue, Cardiopulmonary Resuscitation Certification, Advance Directives and Determination of Death were all reviewed and completed.
- Re-education and staff knowledge competencies of licensed nursing staff and certified nurse aides for Basic Life Support and Cardiopulmonary Resuscitation, and Code Blue Procedure, were initiated.
- The facility would add and conduct cardiopulmonary resuscitation and basic life support training to a semi-annual schedule with competencies.
- The facility would add and conduct semi-annual cardiopulmonary resuscitation drills across all shifts.
- All residents' Advance Directives were audited and completed.
- All residents' Full Code (heart symbol) bracelets were audited and completed.
- All licensed staffs' cardiopulmonary resuscitation certifications were audited and completed.
- All staff present on the unit at the time of the incident were interviewed.
- Resident #1's medical record and staff statements were reviewed and completed.
- A Root Cause Analysis of the incident and Quality Assurance and Performance Improvement meeting was initiated and completed.
- Resident deaths in the last six (6) months were reviewed.
- A Quality Assurance and Performance Improvement for Basic Life Support and Cardiopulmonary Resuscitation was initiated.
- Licensed Practical Nurse #1 was terminated from employment and reported to the New York State Office of Professions Licensing Board.
- Licensed Practical Nurse #2 was terminated from employment and reported to the New York State Office of Professions Licensing Board.
- There would be unannounced, random staff knowledge competencies for Code Blue and Cardiopulmonary Resuscitation and the results would be reported to the Quality Assurance and Performance Improvement Committee. The Quality Assurance and Performance Improvement Committee would determine the need for ongoing monitoring. The responsible party would be the Director of Nursing/Assistant Director of Nursing.
- Mock Code and Cardiopulmonary Resuscitation Drills and post-review would be done across all shifts. The performance reviews/results would be presented to the Quality Assurance and Performance Improvement Committee. The Quality Assurance and Performance Improvement Committee would determine the need for ongoing reporting. The responsible party would be the Director of Nursing/Director of Education.
- The audits on Full Code (cardiopulmonary resuscitation) identifier bracelets would be done and results would be reported to the Quality Assurance and Performance Improvement Committee. The Quality Assurance and Performance Improvement Committee would then determine the need for ongoing reporting. The responsible party would be the Director of Nursing/Assistant Director of Nursing.
- An audit tool was developed to track every admission and re-admission's Advanced Directives. The responsible party would be the Director of Nursing/Assistant Director of Nursing.
- A comprehensive education syllabus was in development for presentation at orientation and annually on the following topics: Advance Directives, Code Blue, Cardiopulmonary Resuscitation, and Nurse Scope of Duties. The responsible party would be the Director of Nursing/Assistant Director of Nursing.
- All licensed nursing staff were educated on Acute Changes in Condition: Basic Life Support and Cardiopulmonary Resuscitation, and Code Blue Procedure.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
The facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, Resident #12 had unclean and untrimmed fingernails despite being observed multiple times over several days. The resident's care plan required total assistance for showering and extensive assistance for personal hygiene, but these needs were not met. Interviews with staff confirmed that nail care should have been performed during the resident's shower, but it was not done, placing the resident at risk for infection and injury. Resident #40 was not assisted out of bed for toileting, despite their care plan indicating they required substantial assistance and had a scheduled toileting routine. The resident expressed a desire to get out of bed and use the bathroom but stated that staff did not assist them due to a previous fall. Observations and interviews revealed that the resident had not been out of bed for toileting for six months, leading to the use of incontinence briefs instead. Resident #58 was not assisted with toileting every 2 hours as care planned. The resident, who had severely impaired cognition and required extensive assistance with toileting, was observed to have gone over 4 hours without being toileted. Staff interviews indicated a lack of adherence to the care plan, with the certified nurse aide admitting to not providing the necessary toileting assistance and failing to inform the nurse. This neglect in following the care plan put the resident at risk for skin breakdown and other complications.
Staffing Shortages Lead to Deficiencies in Resident Care
Penalty
Summary
The facility did not ensure sufficient nursing staff to meet the needs of all residents, leading to deficiencies in resident care. During a confidential resident group meeting, residents reported that their call bells were not answered timely, and meals were not served hot due to staff shortages. The facility's staffing schedule from 4/9/2024 to 4/12/2024 showed that the actual staffing levels were consistently below the desired numbers for registered nurses, licensed practical nurses, and certified nurse aides across all shifts. This staffing shortfall affected the quality of care provided to residents, as evidenced by specific incidents involving inadequate assistance with activities of daily living, such as toileting and mobility, and delays in meal service, resulting in food being served at unappetizing temperatures. Additionally, residents were not provided with meaningful activities that met their interests and preferences due to the lack of staff. For example, one resident who required assistance of two staff members for care was not able to participate in activities or receive timely care, leading to extended wait times for essential services. Interviews with staff confirmed that the lack of sufficient personnel made it difficult to provide timely and adequate care to residents. The facility's administrator acknowledged the staffing issues and mentioned ongoing efforts to recruit and retain staff, including job fairs, pay rate increases, and sign-on bonuses. However, the immediate impact of the staffing shortages was evident in the compromised quality of care and resident dissatisfaction. The facility's policy on nursing service staffing and the facility assessment indicated that the staffing plan was based on resident needs, but the actual staffing levels did not meet these requirements during the survey period.
Infection Control Deficiencies
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, Resident #280 was admitted to the facility with a diagnosis of COVID-19, and transmission-based precautions were not maintained. Observations revealed that staff did not consistently use the required personal protective equipment (PPE), such as N95 masks and eye protection, and the signage outside the resident's room was incorrect, leading to confusion about the necessary precautions. Additionally, there was no dirty linen receptacle set up in or outside the resident's room, and staff were observed not following proper hand hygiene protocols. Residents #37 and #105, who had indwelling medical devices, were not placed on enhanced barrier precautions as required. Observations showed that the rooms of these residents did not have the necessary signage indicating enhanced barrier precautions, and staff did not consistently wear gowns and gloves when providing care. Interviews with staff revealed a lack of understanding and inconsistent implementation of the enhanced barrier precautions, which are critical for preventing the spread of infections among residents with indwelling medical devices. During a medication administration observation, an LPN did not perform hand hygiene between residents, which is a fundamental practice to prevent the spread of infections. The LPN was observed handling medications and interacting with multiple residents without performing hand hygiene, even when entering and exiting rooms with enhanced barrier precautions. This failure to adhere to basic infection control practices further compromised the safety and well-being of the residents in the facility.
Ineffective Pest Control Program
Penalty
Summary
The facility did not maintain an effective pest control program, resulting in the presence of fruit flies in the main kitchen and drain flies in the 2nd, 3rd, and 4th floor tub rooms. Observations made during the recertification survey revealed 15 live fruit flies in the dish machine area of the main kitchen, 3 live and multiple dead drain flies in the 4th floor tub room, 15 live drain flies in the 2nd floor tub room, and 10 live and multiple dead drain flies in the 3rd floor tub room. The third-party pest control vendor service inspection reports from 11/17/2023 to 4/10/2024 did not document the presence of these pests, despite the facility's Pest Activity/Sightings Log indicating fruit flies in the main kitchen on multiple occasions between January and April 2024. During an interview, the Environmental Services Manager stated they were unaware of the drain flies in the 2nd, 3rd, and 4th floor tub rooms and that these rooms were actively used by residents. They also mentioned that the fruit fly traps in the 4th floor tub room were not placed by the environmental services or maintenance departments. The manager expected staff to report pest sightings via phone calls, after which they would contact the pest control vendor. However, they were not aware of the main kitchen's internal pest log sheet and acknowledged that the monthly pest control vendor service inspection reports did not document any fruit flies or drain flies during the specified period.
Breach of Resident Privacy and Confidentiality
Penalty
Summary
The facility did not ensure residents' right to privacy and confidentiality of medical records was maintained for three residents. Specifically, the electronic medication administration records that displayed health information for these residents were left open on the medication cart and were visible to passersby in the hallway. During continuous observation, the medication cart was found unattended multiple times with the computer screen displaying photographs and identifying health information of the residents, making it visible to anyone passing by. Licensed practical nurse #8 was observed leaving the medication cart unattended with the screen open while administering medications to residents and obtaining equipment. The Assistant Director of Nursing confirmed that it was inappropriate for the electronic Medication Administration Record to be left open in the hallway and that there was a button to lock the screen to hide residents' personal health information. The facility policy on patient confidentiality was not followed, leading to a breach of resident privacy.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure the development and implementation of a comprehensive person-centered care plan for five of six residents reviewed during the recertification survey. Specifically, Resident #58's care plan did not include the use of a video monitoring device in their room, despite the device being in place due to the resident's history of sexual delusions. The camera was observed in the resident's room, and staff confirmed its use, but it was not documented in the care plan, which is essential for maintaining the resident's dignity and ensuring staff awareness of the monitoring device. Resident #43's care plan did not include the use of anticoagulants or insulin, despite the resident receiving these medications daily for conditions such as diabetes and atrial fibrillation. The absence of these critical medications in the care plan means that staff may not be aware of the necessary precautions and monitoring required for the resident's safety, such as watching for signs of hyperglycemia, hypoglycemia, and bleeding risks. Similarly, Resident #97's care plan did not include the use of antipsychotics, even though the resident was receiving Seroquel for dementia with psychotic disturbances. The lack of documentation in the care plan could lead to staff being unaware of the medication's side effects and necessary monitoring. Interviews with staff, including registered nurses and the Assistant Director of Nursing, confirmed that medications should be included in the care plans to ensure proper care and monitoring, highlighting a significant oversight in the facility's care planning process.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility did not ensure residents were provided an ongoing program to support their choice of activities, designed to meet their interests and support their physical, mental, and psychosocial well-being. Specifically, two residents were not provided meaningful activities that met their interests and preferences. Resident #40, who had diagnoses including macular degeneration, glaucoma, and difficulty walking, expressed that they were unable to attend music activities due to insufficient staff to assist them out of bed. The resident also mentioned a fear of being left in a chair and not being put back to bed after activities. Despite the resident's interest in music and going outside, there was no documented evidence of staff offering these activities or the resident refusing them. The Director of Activities acknowledged that staff might not invite the resident to activities due to perceived continuous refusals, and there was no documentation of the reasons for these refusals. Resident #79, who had diagnoses including limitation of activities due to disability, adjustment disorder with depressed mood, and cognitive communication deficit, also did not receive activities that met their preferences. The resident's care plan indicated a preference for music, being around animals, keeping up with the news, and going outside. However, the resident's representative and staff interviews revealed that the resident did not leave the unit to attend activities due to insufficient staff to assist with transfers. The resident was observed in bed or in a recliner chair during the survey period, and the activity records showed limited participation in activities. Staff confirmed that the resident enjoyed music, television, and fidget toys but rarely saw activities staff on the unit and had not attended any recent activities. The Director of Activities stated that activities were important for the residents' quality of life and acknowledged that Resident #79 loved video games, which were provided but could not be left alone with the resident. The resident's family played games with them during visits. The Director also noted that the resident had recently watched a movie but had refused some activities. The facility's failure to provide meaningful activities that met the residents' interests and preferences was evident in the lack of staff support and documentation of activity refusals.
Failure to Administer Diuretic and Monitor Weights for Resident with Congestive Heart Failure
Penalty
Summary
The facility did not ensure that Resident #278 received treatment and care in accordance with professional standards of practice. Resident #278, who was admitted with congestive heart failure, had hospital discharge orders for torsemide and instructions for monitoring weights. However, the torsemide was not ordered until five days after admission, and weights were not monitored as recommended. The facility's policy required that physician orders be entered into the electronic record and checked by two nurses on admission, but this process failed in the case of Resident #278. The resident's hospital discharge summary documented a diagnosis of chronic combined heart failure and included specific instructions for torsemide administration and weight monitoring. Despite this, the facility's admission assessment did not include an admission weight, and the initial physician orders did not include torsemide or weight monitoring. The resident expressed concern about not receiving their diuretic for the first few days and not being weighed daily as instructed. Interviews with facility staff revealed that the process for entering and checking new admission medications involved multiple steps, including reconciliation from the hospital discharge summary and a second check by another registered nurse. However, this process was not followed correctly for Resident #278, resulting in the omission of the critical diuretic medication and weight monitoring. Staff acknowledged the importance of these orders for a resident with congestive heart failure and recognized the potential adverse effects of not receiving the prescribed treatment.
Failure to Ensure Proper Cleaning of CPAP Equipment
Penalty
Summary
The facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. Specifically, Resident #278, who had diagnoses including acute on chronic congestive heart failure, hypertensive heart disease, and sleep apnea, received continuous positive airway pressure (CPAP) therapy without a plan to regularly clean the machine to prevent contamination. The facility's policy required daily cleaning of the mask cushion and humidifier tub, and weekly cleaning of the tubing, but these instructions were not included in the resident's care plan or treatment administration records. The resident expressed concerns about the lack of cleaning, and staff interviews confirmed that cleaning instructions were missing from the treatment records, which could lead to bacterial buildup and potential infections. The deficiency was observed during a recertification survey conducted from 4/9/2024 to 4/12/2024. Interviews with various staff members, including a registered nurse supervisor, a licensed practical nurse, and a respiratory therapist, revealed that the CPAP therapy required orders for use and cleaning, but these were not documented in the resident's care plan or electronic health records. The staff acknowledged that the lack of proper cleaning could result in respiratory infections. The facility failed to follow its own policy and the manufacturer's recommendations for maintaining the CPAP equipment, leading to a potential risk for the resident's health.
Significant Medication Errors Identified
Penalty
Summary
The facility did not ensure that residents were free from significant medication errors for two of the five residents reviewed. Specifically, one resident did not receive sacubitril-valsartan, a medication used to treat heart failure, as ordered. During a medication pass observation, the LPN failed to administer the sacubitril-valsartan and incorrectly documented it as given. The LPN later claimed the medication was discontinued and the pharmacy was notified, but there was no documented evidence to support this claim. Attempts to follow up with the LPN were unsuccessful, and the physician was not informed of the missed medication. Another resident did not receive multiple medications as ordered, including brimonidine tartrate eye drops for glaucoma, ammonium lactate lotion for dry skin, docusate sodium for constipation, and Juven, a protein supplement. During a medication pass observation, these medications were not administered, yet the LPN signed off on the Medication Administration Record as if they had been given. The Assistant Director of Nursing confirmed that staff should follow medication orders and document accurately if medications are not given. The physician caring for this resident was not made aware of the missed medications, which could have led to negative effects on the resident's health. The facility's policy on Medication Transcription and Administration, reviewed in 2020, was not followed, leading to these significant medication errors. The policy required medications to be administered accurately and safely, with proper documentation. The failure to adhere to this policy resulted in residents not receiving essential medications for their medical conditions, and there was a lack of communication and documentation regarding the missed doses.
Failure to Provide Dental Services
Penalty
Summary
The facility did not assist Resident #102 in obtaining routine and emergency dental care despite the resident's complaints of tooth pain and concerns about tooth decay. The resident, who had diagnoses including complete quadriplegia, acute and chronic respiratory failure, and ventilator dependence, had not seen a dentist since their admission in December 2023. The resident expressed concerns about the potential danger of bacteria from their mouth entering their respiratory tract, which could be particularly harmful given their compromised respiratory status. Despite informing a nurse about the tooth pain, there was no documentation of dental concerns or a dental consult in the resident's medical record. Interviews with staff revealed that the facility's policy required a dental consult to be ordered on admission, but this was not done for Resident #102. The Assistant Director of Nursing confirmed that a dentist visited the facility weekly and that dental consults should be ordered by the nurse handling admission orders. However, Resident #102 had not been seen by a dentist, and there was no comprehensive care plan addressing the resident's oral health concerns. The failure to provide necessary dental care was acknowledged by the staff, who recognized the increased risk of infection for residents with respiratory compromise.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility did not ensure that food and drink provided to residents were palatable, flavorful, and served at appetizing temperatures. During the recertification survey, it was observed that food temperatures were not maintained as per the facility's policy. Specifically, during the lunch meal on 4/12/2024, cold food items were served at temperatures higher than the required 41 degrees Fahrenheit. For instance, milk was measured at 48 degrees Fahrenheit, apple juice at 47 degrees Fahrenheit, tossed salad at 60 degrees Fahrenheit, and cut fruit bowl at 49 degrees Fahrenheit. This discrepancy was confirmed by the Food Service Director, who acknowledged the difficulty in maintaining proper temperatures when hot and cold food items were kept in the same meal cart. Interviews with residents and staff revealed that meals were often served cold due to delays in meal tray distribution. Resident #66 and Resident #4 both reported receiving cold meals, with Resident #66 preferring to eat in their room and Resident #4 requiring assistance with meals. Additionally, during a resident meeting, 12 anonymous residents expressed concerns about the timely distribution of meal trays, attributing delays to insufficient staff. Certified nurse aide #14 confirmed that the speed of meal tray distribution depended on the number of staff available, and meal carts were not separated based on where residents ate their meals.
Deficiencies in Food Storage and Cleanliness in Main Kitchen
Penalty
Summary
The facility did not ensure the storage, preparation, distribution, and service of food in accordance with professional standards for food service safety in the main kitchen. Observations made during the survey revealed that the floor of the dairy walk-in cooler was stained and sticky, and the floor under the walk-in cooler shelves had food items and other debris. Additionally, there were 18 pans improperly stacked on the clean drying rack, with the bottom of one pan in direct contact with the cooking side of another, posing a potential contamination risk. The Food Service Director confirmed these findings and acknowledged that the pans should have been moved to the back storage room and that the stickiness in the dairy walk-in cooler was due to a spilled gelatin product that was not cleaned up immediately by the staff who spilled it. The facility's documentation indicated that the night supervisor was responsible for ensuring the general cleanliness of the kitchen and that the stock person was responsible for cleaning under the shelves in the coolers and freezer. However, the Food Service Director admitted that the staff did not always document when issues were identified and verbally instructed to be fixed. The undated Food Service-Receiver Performance Evaluation Form and the Master Cleaning Schedule also outlined responsibilities for cleaning the walk-in refrigerators and freezers, but these procedures were not adequately followed, leading to the observed deficiencies.
Failure to Ensure Proper Pressure Ulcer Care
Penalty
Summary
The facility did not ensure that a resident with pressure ulcers received the necessary treatment and services to promote wound healing, prevent infection, and prevent new pressure ulcers from developing. Specifically, the resident developed facility-acquired pressure ulcers and had a physician order for a specialty mattress, which was not checked for function for 14 days after it was ordered. The mattress was observed not connected to the pump, and the pump was not operational. The resident had multiple diagnoses, including a left femur fracture and facility-acquired Stage 2 pressure ulcers on the back and sacral region. The resident was cognitively intact, dependent for bed mobility and transfers, and had pressure ulcers that were not present on admission. The resident's care plan included turning and repositioning every 2 hours, treatment per physician order, and pressure-relieving boots, which the resident frequently refused. Despite these measures, the resident developed additional pressure ulcers, and there was no documented evidence that the specialty mattress was checked for functioning every shift as ordered. Observations revealed that the air mattress pump was not operational, and the tubing was not connected. Licensed practical nurses documented that the mattress function was checked, but the pump was found to be broken and not functioning. Interviews with staff confirmed that the air mattress was not in use despite being ordered, and the broken pump device was not reported for repair. The Assistant Director of Nursing acknowledged that the air mattress was essential for reducing pressure and preventing further deterioration of the resident's pressure ulcers.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the appropriate liability and appeal notices to a Medicare beneficiary, specifically for a resident who remained in the facility after the discontinuation of Medicare Part A services. The resident, who had severe cognitive impairment and was admitted with diagnoses including a left femur fracture, depression, and cerebral palsy, did not receive the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055. The resident's Medicare Part A skilled services ended on 2/24/2024, but the notice was not issued, and the resident stayed in the facility until 3/12/2024. Interviews with facility staff revealed a lack of clarity regarding the responsibility for issuing the SNF ABN. The patient account supervisor acknowledged that the notice should have been issued within 48 hours prior to the termination of Medicare Part A services. However, the Director of Social Work believed that the business office was responsible for issuing the notice and was unaware that the resident should have received it. This miscommunication led to the failure to provide the necessary notice to the resident or their representative.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 211 citations issued within 25 miles in the last 12 months — including the 4 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oneida
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Grand Rehabilitation And Nrsg At Chittenango | 11 mi | ★★★★★ | 18 | 0 |
| Crouse Community Center Inc | 12.9 mi | ★★★★★ | 0 | 0 |
| The Grand Rehabilitation And Nursing At Rome | 14.2 mi | ★★★★★ | 29 | 1 |
| Betsy Ross Rehabilitation Center, Inc | 14.2 mi | ★★★★★ | 2 | 0 |
| Katherine Luther Residential Hlth Care & Rehab | 14.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.