Below 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 Onondaga Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
An LPN found a full-code resident unresponsive, cold, rigid, and without a pulse or respirations, but did not start CPR because the resident appeared deceased. The LPN called the DON and on-call provider, and a supervisor later called 911; EMS arrived and pronounced the resident dead. The resident had a CPR order and MOLST indicating CPR should be attempted.
A facility failed to promptly notify the ordering practitioner of abnormal and critical lab results for three residents. One resident with COPD and HTN had multiple abnormal CBC/BMP/BNP values, another resident with ESRD and dialysis had a critical creatinine, and a third resident with MRSA infection and acute kidney failure had abnormal CBC results and a positive wound culture. Surveyors found delayed review, no timely nursing documentation, and no documented provider notification when the results were first available.
Lack of qualified CPR-certified staff on duty: Surveyors found the facility did not ensure CPR services were provided by staff with accepted national CPR certification for 38 residents with CPR orders. The facility assessment did not include BLS or CPR certification needs, several LPNs had no documented CPR certification, and two LPNs held online-only CPR credentials without hands-on skills validation. Nursing schedules showed shifts staffed only by an LPN supervisor or LPNs whose CPR status was undocumented or based on online training, and leadership stated they did not know who tracked CPR certifications or that the certifications lacked hands-on evaluation.
Food storage, cooling, and sanitation practices were not maintained according to policy. Surveyors observed trays from the prior meal left in the dining room, a sticky and unclean floor, food boxes stored on the floor, unlabeled and undated items in coolers, raw eggs stored above ready-to-eat foods, and unclean equipment and dish areas. A container of soup remained at 44 degrees F with no cooling logs documented, and the FSD stated the soup had been transferred after the meal and should be discarded if not cooled properly.
Administration did not ensure CPR readiness, timely lab result notification, or documented nursing competencies. A resident was found pulseless and apneic, but staff did not start CPR per the MOLST. Several residents had abnormal lab results that were not promptly reported to the ordering physician, and multiple LPNs lacked documented annual education/competencies tied to the facility assessment; one LPN also did not provide feeding tube care that met professional standards.
A resident with a history of falls and multiple medical conditions experienced an unwitnessed fall and was found on the floor by a roommate. Although LPNs and CNAs checked the resident's vitals and safety, there was no documented assessment by a qualified professional, such as an RN or via telehealth, as required by facility policy. The resident's care plan indicated a need for assistance with toileting and mobility, but the required post-fall assessment was not completed or documented.
Surveyors found that two residents did not receive adequate supervision or accident prevention measures as required by their care plans. One resident on aspiration precautions was left unsupervised during meals and given a straw, contrary to orders, while another resident at risk for falls did not have fall mats in place and could not reach their call light. Staff interviews and observations confirmed these deficiencies in supervision and implementation of safety interventions.
Failure to provide Medicare non-coverage notices to two residents. The facility did not document issuance of the required CMS-10123 notice when Medicare Part A skilled coverage ended for two beneficiaries. Staff identified that the BOM was responsible for the notices, but records for the residents could not be located, and the MDS Coordinator and Administrator confirmed there were gaps in the beneficiary notification process and missing documentation.
Failure to report a CPR-related incident: A resident with a MOLST requesting CPR was found unresponsive without a pulse or respirations, and the LPN determined CPR was futile based on the resident’s condition. The provider, 911, EMTs, and police were called, and the resident was pronounced deceased, but the incident was not reported to the NYSDOH even though staff later stated it should have been reported.
An LPN performed feeding tube care for a resident with stroke and dysphagia in a way that did not meet infection control standards, including disconnecting the tube feeding and placing the formula bottle in the trash while still connected to the resident. The facility also lacked documented annual education and competencies for five reviewed LPNs, including required orientation and skills tied to the Facility Assessment such as enteral feeding, PPE, wound care, medication administration, and hand hygiene.
Infection control precautions were not consistently followed for residents on EBP or transmission-based precautions. A resident with a urinary catheter had no precaution signage at times, and the catheter bag was observed uncovered and resting on the floor. An LPN disconnected another resident’s tube feeding wearing gloves but no gown, and a CNA entered a room for hands-on care without PPE for a resident on EBP with MRSA and wounds.
Resident Rights and advocacy information were not posted in a resident-accessible manner, and multiple residents stated they did not know where to find the state complaint hotline, Ombudsman, or other State agency information. Surveyors observed the postings in locked glass cabinets above eye level and in small print, and staff acknowledged the information was not accessible to all residents.
A resident with Parkinson's and anxiety was physically abused by an LPN, who pushed them into a wall, causing a nosebleed and fractured nose. The resident's care plan noted behavioral symptoms, but the LPN's response was abusive. Witnesses confirmed the incident, leading to the LPN's arrest and charges of assault and endangering a vulnerable adult.
The facility failed to treat residents with respect and dignity, including incidents of staff having a verbal confrontation in front of a resident, standing over a resident while feeding, not timely removing a disruptive resident, and entering a legally blind resident's room without announcing themselves.
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents, with issues including used incontinence briefs left in rooms, broken door handles, missing light fixture covers, exposed wiring, and serving cold beverages in disposable cups. Staff interviews confirmed these practices were not in line with facility policies.
The facility failed to ensure residents received necessary assistance with activities of daily living, including dressing, bathing, and meal supervision. One resident was observed wearing the same nightgown for three days, another did not receive a shower for three weeks, and a third was left to eat alone without supervision. Staff interviews confirmed these deficiencies, which were contrary to the residents' care plans.
The facility failed to ensure timely meal delivery, with meal trays arriving up to 1 hour and 25 minutes late due to kitchen staffing issues. Interviews with residents and staff confirmed the delays, and the Food Service Director acknowledged the problem, citing staffing shortages as the cause.
The facility failed to maintain an effective infection control program and lacked a comprehensive water management plan. Staff did not adhere to PPE protocols for residents on precautions, and there were inconsistencies in Legionella testing, highlighting significant oversights in maintaining a safe environment.
The facility's main kitchen had several deficiencies, including broken cooler and freezer doors, cracked floor tiles, and water leaks, leading to unsanitary conditions. The cleaning policy was not followed, and there was no documented cleaning schedule. Staff interviews revealed that these issues had persisted for months without proper documentation or repairs.
The facility failed to maintain proper temperatures in unit kitchenette refrigerators, with one labeled out of order and another showing discrepancies between recorded and actual temperatures. Staff interviews revealed awareness of the issue, but documentation was not provided when requested.
A resident with chronic kidney disease and acute kidney failure did not receive a recommended follow-up appointment with a nephrologist. Despite multiple notes and attempts to schedule the consult, the appointment was never secured, leading to a significant gap in care. The facility's process for scheduling and tracking consultations was inadequate, resulting in the resident's ongoing dissatisfaction and potential health risks.
The facility failed to provide adequate supervision and a hazard-free environment for two residents. One resident with legal blindness had their bed not in the low position and call bell out of reach, while another resident with dementia was observed wandering unsupervised into other residents' rooms. Staff interviews revealed a lack of adherence to care plans and insufficient monitoring, leading to unsafe conditions.
The facility failed to ensure a resident maintained acceptable nutritional status by not weighing them as ordered, not providing fortified pudding, and not assisting with meals as care planned. The resident had severe protein-calorie malnutrition and required tube feedings and a mechanically altered diet. The resident's weight was not monitored as required, and their nutritional needs were not reassessed. Staff did not consistently assist the resident with eating, leading to low meal intakes.
A resident with end-stage renal disease was found with lidocaine-prilocaine cream at their bedside without a documented assessment for self-administration. The facility's policy required such an assessment, but it was not conducted. Staff interviews confirmed that medications should not be kept at the bedside without a physician order, which was absent in this case.
A resident with dementia and depression, who required an interpreter due to a language barrier, did not have a comprehensive care plan addressing their communication needs or potential victimization risk. Observations showed the resident was not understood by staff, leading to frustration and aggressive behavior. Staff lacked awareness and access to communication tools, despite facility policies on translation services and resident rights.
The facility failed to provide individualized activity programs for two residents, resulting in a deficiency in meeting their physical, mental, and psychosocial well-being. One resident, with depression and an amputation, was not engaged in activities of their choosing due to discomfort and lack of in-room activities. Another resident, with dementia, was observed sitting in the hallway without staff interaction or activities, despite having a care plan that included interests like music and animals. The Activities Director acknowledged insufficient one-to-one visits and ineffective use of the daily chronicle.
A resident with end-stage renal disease did not receive appropriate dialysis care as their dialysis access site dressing was not removed by nursing staff as ordered. The resident had to remove the dressing themselves before their next dialysis session. The facility lacked documented hemodialysis agreements or procedures, and nursing staff failed to monitor the access site properly, leading to a deficiency identified during a survey.
A survey found that a facility failed to properly label and store medications, including insulin pens and an inhaler, on a medication cart. The medications lacked opened or expiration dates, which could affect their effectiveness. An LPN and RN Unit Manager acknowledged the oversight, with the RN confirming monthly audits for expired medications. A pharmacist later clarified the expiration period for the inhaler.
The facility failed to serve food at appropriate temperatures, with test trays showing beef stew and vegetables below required temperatures and French fries cold and undercooked. The Food Service Director acknowledged the issue, citing the lack of plate warmers, and the facility could not provide documentation of test trays.
A resident with dementia and diabetes was served a meal inconsistent with their physician-ordered mechanical soft diet, containing large chunks of beef instead of ground beef. Staff interviews revealed lapses in checking meal consistency, leading to the resident receiving a regular diet meal instead of the required modified diet.
A resident's call bell was repeatedly found out of reach, preventing them from contacting staff for assistance. Despite the facility's policy requiring call bells to be accessible, observations during a survey revealed the call bell on the floor multiple times. Staff interviews confirmed the importance of having the call bell within reach, especially for residents like this one, who had moderately impaired cognition and were dependent on staff for daily activities.
The facility failed to maintain an effective pest control program, leading to evidence of mice in a resident room. A resident reported recent mouse sightings, confirmed by their roommate. Inspection revealed rodent droppings and chewed wrappers inside the heater, which had an open hole allowing pest entry. The Administrator noted that housekeeping and maintenance were responsible for pest management.
Failure to Initiate CPR for Full-Code Resident
Penalty
Summary
The facility failed to provide CPR prior to the arrival of emergency medical personnel for a resident who had a physician order for CPR and a MOLST indicating that CPR should be attempted. Resident #85 had diagnoses including COPD, hypertension, and anxiety disorder, and was documented as cognitively intact on the admission MDS. The resident’s orders and MOLST both reflected full-code status, with CPR to be initiated if the resident had no pulse and/or was not breathing. On the morning of the event, an LPN entered the resident’s room and found the resident unresponsive, cold to the touch, rigid, with no color, no respirations, and no pulse. The LPN documented that the resident appeared clearly deceased and did not start CPR because they believed it would be futile based on the resident’s condition. The LPN called the DON and the on-call provider service, but no return call was received before EMS became involved. Another nursing supervisor arrived later and called 911. EMS arrived and pronounced the resident deceased. Statements and documentation in the record showed that staff recognized the resident was full code, but CPR was not initiated when the resident was found without a pulse and without respirations. The LPN stated they did not begin CPR because of the resident’s rigidity and signs of death. The DON, physician, and administrator all stated that a full-code resident should receive CPR, although they also referenced rigidity as a possible reason not to start resuscitation. The deficiency involved one resident and was cited as Immediate Jeopardy and Substandard Quality of Care.
Delayed Review and Notification of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering practitioner of laboratory results that were outside clinical reference ranges for 3 residents. Surveyors found that abnormal and critical lab results were received in the electronic medical record, but there was no timely documented review, no documented provider notification, and no consistent nursing follow-up in the records reviewed. One resident had hypertension and COPD and was cognitively intact. Routine CBC, BMP, and BNP results showed multiple abnormal values, including low sodium, low chloride, elevated BUN, elevated glucose, and low red blood cell indices. The lab report showed the results were available and later reviewed by the Acting DON more than a month after receipt, with no documented nursing progress note or provider communication addressing the abnormal findings when they were first available. A second set of abnormal BMP results for the same resident showed sodium 121, potassium 5.8, chloride 90, elevated BUN, and elevated BUN/creatinine ratio. The report showed the results were later reviewed by an LPN assistant unit manager, but there were no nursing or provider notes addressing the abnormal values before the resident expired. Another resident had end stage renal disease and dialysis dependence. A lab report showed a critical creatinine of 10.89, but there was no documented nursing progress note or provider notification when the result was received. The provider later documented discussion of other lab abnormalities, including low hemoglobin and hematocrit, but the critical creatinine was not addressed in that note. A third resident had a right below-knee amputation, MRSA infection, and acute kidney failure. CBC, procalcitonin, and wound culture results showed anemia and a wound culture positive for MRSA with sensitivities, but there was no documented nursing note or provider communication when the results were available. The provider later documented the MRSA-positive culture and started antibiotics, but the survey found the results had not been reviewed timely.
Lack of Qualified CPR-Certified Staff on Duty
Penalty
Summary
The facility did not ensure that services provided or arranged were delivered by individuals with the skills to perform CPR in accordance with each resident’s written plan of care for 38 residents with CPR orders. Surveyors found that staff with current CPR certification meeting accepted national standards were not present in the building 24 hours per day, and the facility assessment did not include Basic Life Saving skills or identify individuals requiring CPR certification. The job descriptions for LPN, RN Supervisor, RN, and Unit Manager required current license or certification, but CPR certification or Basic Life Saving skills were not listed as job requirements. Record review showed no documented evidence that several LPNs had CPR certification, while two LPNs had certifications from organizations that offered online-only training. The National CPR Foundation materials stated online training was legal and acceptable, but in-person training was not offered and employers or licensing boards could require in-person training. The American Health Care Academy website documented CPR certification was offered online, and when the facility contacted customer service, it was confirmed that one LPN had only purchased and completed the online course and had not completed the hands-on skills portion. The nursing schedules reviewed showed that on multiple shifts, the only nurses on duty were staff whose CPR certification status was either undocumented or based on online-only training. During interviews, the Administrator and Corporate Director of Clinical Transformation stated they had to review staff CPR certifications because they did not know the National CPR Foundation certifications did not include a hands-on skills evaluation. The DON stated they were not sure when the training concerns were identified and did not know the process for licensed staff to complete CPR certification, while the Administrator stated they did not know who tracked CPR certifications and that they were supposed to track the hands-on competencies for CPR certifications.
Food Storage, Cooling, and Dining Room Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the main kitchen and dining room. The facility’s policies required rapid cooling of time/temperature control for safety foods, proper labeling and dating of stored foods, storage off the floor, and cleaning of dining room floors and dishware after meals. During the survey, the main dining room had several meal trays from the previous dinner meal on a rolling rack, and the floor was unclean and sticky, with the surveyor’s foot sticking to the floor while walking through the area. In the main kitchen, surveyors observed several boxes of food stored on the floor, including crackers, canned soup, and other dry goods. In the walk-in cooler, there were dated pans of corn and pineapple, but also several 2-ounce souffle cups that were unlabeled or undated, as well as undated sandwiches in a preparation cooler. On a later observation, raw eggs were stored on a shelf above sliced apples, pudding, and pickles in the walk-in cooler. The meat slicer was observed with dried food debris, the handwashing sink contained dried paper towels and a Band-Aid, and the dish room and three-bay sink area had numerous unclean dishes, pots, and pans stacked up. The survey also identified improper cooling of soup. A container of vegetable soup in the walk-in cooler measured 44 degrees Fahrenheit and remained at 44 degrees Fahrenheit when rechecked later. There was no documented evidence of completed food cooling logs. The Food Service Director stated the soup had been from the previous dinner meal, had been transferred into a 3-gallon container after being placed in a shallow pan, and that the soup should be discarded if it was not cooled properly. The Food Service Director also stated food products should not be stored on the floor, dishes should be washed after every meal, all items in coolers should be labeled and dated, the meat slicer should be cleaned after each use, and raw food should not be stored above ready-to-eat food.
Administration Failed to Ensure CPR, Lab Notification, and Nursing Competency Oversight
Penalty
Summary
Administration failed to ensure the facility was operated in a manner that used its resources effectively and efficiently to support resident care, with deficiencies identified in cardiopulmonary resuscitation, laboratory notification, and nursing staff competency. The report states that these failures contributed to Immediate Jeopardy findings in F678 and F773, and that nursing staff did not have appropriate competencies and skill sets to provide safe care under F726. The facility assessment described an average daily census of 75 residents and listed diagnoses including psychiatric and mood disorders, diabetes, skin ulcers, infections with multi-drug-resistant organisms, renal failure, and other complex conditions, along with services such as tube feeding, wound care, therapy, medication administration, and end-of-life care. Resident #85 was found without a pulse and without respirations on 07/22/2025, and staff did not initiate CPR in accordance with the resident’s wishes documented on the MOLST. The report states this resulted in actual harm that was Immediate Jeopardy and substandard quality of care to residents’ health and safety. The deficiency was tied to administration’s failure to ensure licensed staff had the required CPR certification and that the Assistant DON was overseeing completion of CPR certifications with a hands-on component, as described by the Administrator. The report also states that residents #85, #60, and #41 had laboratory results outside the clinical reference range and the ordering physician was not promptly notified. This was identified as Immediate Jeopardy with the likelihood of serious injury, serious harm, or death. In addition, LPNs #6, #7, #10, #27, and #29 did not have documented annual education or competencies aligned with the facility assessment, and LPN #29 did not provide feeding tube care that met professional standards. During interviews, the DON stated there were concerns about staff training before survey but could not identify what or when they were identified, and the Administrator and DON were unsure how CPR certifications and competencies were being tracked before survey entrance.
Failure to Ensure Qualified Assessment After Resident Fall
Penalty
Summary
A deficiency was identified when a resident with a history of falls, chronic obstructive pulmonary disease, hypertension, and anxiety disorder experienced an unwitnessed fall in the evening. The resident was found on the floor by their roommate, and staff documented that vital signs were taken and were stable, with no signs of injury at the time. However, there was no documented evidence that a qualified professional, such as a registered nurse, assessed the resident after the fall, as required by facility policy and professional standards of practice. The facility's Falls Management and Prevention policy required a head-to-toe assessment by a qualified individual following any fall. Documentation from multiple staff members, including certified nurse aides and LPNs, indicated that the resident was checked for safety and vitals were taken, but the assessment by a registered nurse or through telehealth was not completed or documented. Staff interviews revealed that there was no registered nurse in the building during the shift, and although the process was to contact an on-call RN or use telehealth for assessment, this was not done for the resident in question. The resident had a care plan indicating a risk for falls and required assistance with toileting and mobility. Despite these interventions, the resident attempted to toilet independently, resulting in a fall. The lack of a documented assessment by a qualified professional after the incident constituted a failure to provide care in accordance with the resident's care plan and professional standards. The resident expired the following morning, but the report does not link the death directly to the deficiency.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
Surveyors identified deficiencies in the facility's supervision and accident prevention practices for two residents. One resident with diagnoses including dysphagia, dementia, and acute respiratory failure was on aspiration precautions, requiring a mechanical soft diet, nectar thick liquids, no straws, and partial assistance at meals. Despite these orders and care plan instructions, the resident was observed left alone with their meal tray, not assisted as required, and provided a straw by staff. Multiple staff interviews confirmed a lack of clarity and communication regarding who was responsible for assisting the resident, and staff did not consistently follow the aspiration precaution protocols, including supervision during meals and avoidance of straws. Another resident, with a history of diabetic neuropathy, cataracts, obesity, and a documented risk for falls, did not have all planned fall interventions in place. Observations over several days showed that the resident's bed was not consistently in the lowest position, fall mats were not always in place as care planned, and the call light was frequently out of reach, sometimes on the floor under the bed. The resident reported being unable to get help when needed due to the inaccessible call light. Staff interviews revealed inconsistent understanding and implementation of the care plan interventions, with fall mats not always replaced after meals and the call light not reliably positioned within reach. The facility's failure to ensure adherence to individualized care plans and physician orders resulted in residents not receiving adequate supervision or the necessary interventions to prevent accidents. The lack of proper meal assistance and aspiration precautions for one resident, and the absence of required fall prevention measures for another, were directly observed and confirmed through staff interviews and record reviews.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (CMS-10123) to two Medicare beneficiaries whose Part A skilled nursing coverage was ending. Resident #94 had a Medicare-covered stay that began on 04/29/2025, with the last covered day of Part A services on 05/22/2025, and the discharge was a facility-initiated discharge when benefit days were not exhausted. Resident #95 had a Medicare-covered stay that began on 02/11/2025 and ended on 04/07/2025, with a planned discharge and return not anticipated. For both residents, there was no documented evidence that the required notice was provided. During interviews, the Director of Rehabilitation stated the Business Office Manager was responsible for issuing the notice, and in the absence of the Business Office Manager and MDS Coordinator, they were the third person responsible for issuing it. The MDS Coordinator stated the notices should have been issued before the end of coverage, but there was no documentation they were issued. The Administrator stated the Business Office Manager left the facility in June 2025 and that there were gaps in the beneficiary notification process; documentation for resident notifications was not being maintained as it should have been. The report also stated that without the notice, residents would not be advised that Medicare-covered services were ending or of the appeal process, and could potentially be financially responsible for non-covered services.
Failure to Report a CPR-Related Incident
Penalty
Summary
The facility did not ensure that an incident involving Resident #85 was reported to the State Survey Agency within five working days. Resident #85 had diagnoses including chronic obstructive pulmonary disease and hypertension, was cognitively intact on the Minimum Data Set, and had a MOLST signed by the resident requesting CPR if they had no pulse and/or were not breathing. The physician order also documented attempt CPR, but the resident’s comprehensive care plan did not include their resuscitation wishes or orders. The facility investigative summary documented that Resident #85 was found unresponsive, without a pulse or respirations, and that the LPN checked the MOLST and saw the resident wanted CPR. The resident was described as cold, rigid, with blood pooling and dependent lividity, and the LPN stated CPR was futile. The provider and 9-1-1 were called, EMTs and police responded, and the resident was pronounced deceased. The investigation concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, but the incident was not reported to the New York State Department of Health. During interviews, the former DON stated the incident should have been reported and that they were told not to report it, while the Administrator stated they did not report the death because they followed American Heart Association guidelines and believed it was not reportable.
LPN Tube Feeding Care and Missing Nursing Competencies
Penalty
Summary
Licensed Practical Nurse #29 performed feeding tube care for Resident #5 in a manner that did not meet professional infection control standards. Resident #5 had diagnoses including stroke and dysphagia, was severely cognitively impaired, dependent for most activities of daily living, and received 26-50% of total calories through tube feeding. The resident’s care plan and physician orders required enteral feeding with Osmolite 1.2, head-of-bed elevation during administration, and local care to the tube site with monitoring for signs and symptoms of infection. During observation, the LPN disconnected the resident’s tube feeding from the pump while wearing gloves but without a gown. The tube feeding formula bottle was placed in the garbage receptacle while still connected to the resident’s feeding line. The LPN stated they removed the tube feeding so the resident did not have to hear the beeping. In interview, the LPN stated they wore gloves, flushed the line, took down the tube feeding, and threw everything out, and acknowledged that the bottle should not have been connected to the resident when placed in the trash. The ADON stated the proper process was to place the tube feeding on hold, stop the machine, pinch and cap the tube, and cover it, and that it was not acceptable for the bottle to be in the trash can while connected to the resident. The facility also failed to ensure that five of five reviewed LPNs had documented education or competencies completed annually in accordance with the needs identified in the Facility Assessment. Records showed LPNs #6, #7, #10, #27, and #29 lacked documented evidence of job-specific orientation and/or licensed nurse skills competencies, and some lacked general orientation as well. The Facility Assessment identified required nursing competencies including enteral nutrition feeding, PPE, wound care, medication administration, handwashing, and other skills. Interviews with nursing staff and leadership showed that some education consisted of computer-based modules, sign-in sheets, and discussion of printed materials, but hands-on competencies were not completed for several areas, and documentation of required education was missing.
Infection Control Precautions Not Followed for Residents with Catheter, Feeding Tube, and Wounds
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program for residents on enhanced barrier precautions and other transmission-based precautions. The deficiency involved three residents with indwelling devices, wounds, or MDRO-related conditions, and survey observations showed that required precautions were not consistently followed or displayed. The facility policy stated that enhanced barrier precautions applied to residents with MDROs, wounds requiring dressings, and indwelling medical devices such as urinary catheters and feeding tubes, and that signage should be posted and gowns and gloves worn for high-contact care activities. Resident #43 had diagnoses including paraplegia, osteomyelitis of the left foot and ankle, and enlarged prostate, and was cognitively intact, dependent for most ADLs, and had an indwelling urinary catheter. The resident’s care plan addressed MDRO colonization and catheter care, but did not include enhanced barrier precautions. Surveyors observed no transmission-based precaution signage outside the room on 09/22/2025, and later observed the resident’s uncovered urinary collection bag containing tea-colored urine resting directly on the floor without a barrier. Staff interviews confirmed the bag had been on the floor, and staff stated urinary collection bags should not be placed there. Resident #5 had dysphagia, severe malnutrition, and intracranial bleeding, was cognitively impaired and dependent for ADLs, and had a feeding tube. The care plan identified risk for MDRO colonization related to the feeding tube and required enhanced barrier precautions with gown and gloves for high-contact activities. During observation, an LPN disconnected the tube feeding while wearing gloves but no gown. The LPN stated they normally only wore gloves when disconnecting tube feeding and did not wear a gown, despite acknowledging that enhanced barrier precautions required both gloves and a gown because of splash back. Resident #80 had chronic skin ulceration, MRSA, a diabetic foot ulcer, and a stage 4 pressure ulcer, and was dependent for most ADLs with moderately impaired cognition. The care plan documented an actual MDRO infection to wounds and required enhanced barrier precautions. Surveyors observed a CNA enter the room without PPE, carrying linens and supplies, and later reenter without a gown after handling the resident’s sheet. The CNA stated they knew residents on enhanced barrier precautions should have PPE before entry, but were unsure whether the sign applied to this resident or the roommate because no one told them.
Resident Rights and Advocacy Information Not Posted at Accessible Level
Penalty
Summary
The facility did not ensure residents were informed during their stay of their rights and the rules and regulations governing resident conduct and responsibilities. During the recertification survey, eight of ten residents present at the resident group meeting stated they were not aware of where information on the state complaint hotline, the ombudsman, or other pertinent State agencies was posted, and they were not aware of their rights or where those rights were posted. The residents also reported that the state complaint hotline and other pertinent State agencies and advocacy groups were in small print and not posted at a resident-accessible level. Surveyors observed that the Rights as a Nursing Home Resident document, the facility advocacy information, and the ombudsman information were posted in locked glass cabinets at the entrances to the north and south hallways, above standing head height or eye/forehead level, and in small print. Facility staff interviews reflected awareness that the postings were not accessible to all residents, including residents in wheelchairs, and that residents had requested larger postings. The facility policy stated residents had the right to be informed of their rights and to communicate with outside agencies, but the postings observed and the resident interviews showed that the information was not readily accessible to residents.
Resident Abuse by LPN Results in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, resulting in harm. The incident involved a resident with a history of Parkinson's Disease, osteopenia, and anxiety, who was known to exhibit behavioral symptoms such as physical outbursts and frequent requests for anxiety medication. On the day of the incident, the resident approached an LPN to ask about anxiety medication. The LPN, in response, pushed the resident into a wall, causing a nosebleed and a fractured nose. This action was witnessed by multiple staff members and another resident, who reported the incident to the Director of Nursing. The resident's care plan had documented their behavioral symptoms and included interventions such as medication management, psychiatric evaluation, and redirection to a less stimulating environment. Despite these measures, the resident's anxiety had reportedly increased, leading to more frequent aggression towards staff. On the day of the incident, the resident's behavior was consistent with their documented history, yet the LPN's response was inappropriate and abusive, resulting in physical harm to the resident. The incident was reported to the facility's administration, and an investigation was initiated. Witnesses corroborated the resident's account of being pushed into the wall by the LPN. The police were notified, and the LPN was subsequently arrested and charged with assault and endangering the welfare of a vulnerable adult. The facility's failure to prevent this abuse highlights a significant deficiency in protecting residents from harm.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility did not ensure residents were treated with respect and dignity, impacting six residents. Specifically, an activities aide and an LPN had a verbal confrontation in front of a resident after running out of portable oxygen during a group activity. Additionally, a CNA stood over a resident while assisting them with eating, which was against the facility's policy of being at eye level to ensure comfort and proper visualization of chewing and swallowing. Two anonymous residents also reported being told they could not leave their rooms due to a lack of portable oxygen, which restricted their freedom and self-determination. Another resident exhibited continuous disruptive verbal behaviors in a common area and was not removed timely as planned. The resident was also transported in their wheelchair facing backward by a CNA, which was not dignified or respectful. The facility's policy required residents exhibiting behavioral symptoms to be moved to a quiet, controlled space to calm down, but this was not followed. Interviews with staff confirmed that the resident's behavior was disruptive and should have been managed more appropriately. A legally blind resident experienced a lack of respect for their condition when a CNA entered their room without knocking or announcing themselves. The CNA proceeded to reposition the resident without explaining the actions being taken, which left the resident feeling disoriented and uncomfortable. The facility's policy required staff to knock and introduce themselves before entering a resident's room, especially for those with visual impairments, to maintain a homelike environment and ensure the resident's comfort and dignity.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in both the North and South units, as well as the main dining room. On the North unit, surveyors observed used incontinence briefs on the floor and nightstand in resident rooms, a resident who smelled of urine, a broken door handle with sharp edges, and improperly maintained sliding glass door restrictors. Interviews with staff confirmed that used briefs should not be left in resident rooms and that door handles and restrictors should be properly maintained to ensure safety and dignity for residents. On the South unit, surveyors found missing light fixture covers, open light sockets with exposed wiring, and broken door handles in resident rooms. Additionally, there was tape on windows and sliding doors, which had been in place for 1-2 years without proper documentation. Staff interviews revealed that broken equipment should be reported and fixed promptly, and that the tape on windows was not documented or addressed appropriately. In the main dining room, a severely broken table was observed, and residents were served cold beverages in disposable cups, which was not considered homelike. The Food Service Director acknowledged that disposable dishes should only be used in emergencies and that the practice was due to short staffing. Interviews with housekeeping and administrative staff confirmed that broken items should be reported and removed to maintain a safe and clean environment for residents.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
The facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, Resident #1 was observed multiple times over three days wearing the same nightgown, indicating a lack of assistance with dressing. Certified nurse aides confirmed that the resident required assistance with dressing due to poor vision and should have received clean clothing daily, but this was not consistently provided. The resident's care plan and Kardex indicated the need for daily dressing assistance, which was not adhered to by the staff, leading to improper hygiene and potential risk for infection. Resident #12, who required substantial assistance with bathing, reported not receiving a shower until three weeks after admission. The resident's care plan specified shower days twice a week, but the certified nurse aide documentation did not reflect this schedule. Interviews with staff revealed that the resident had not refused care, and the lack of showers was due to time constraints and oversight. This failure to provide regular showers compromised the resident's hygiene and dignity. Resident #35, who required supervision with eating and assistance with transfers, was observed eating alone in their room without supervision on multiple occasions. The resident's care plan indicated the need for supervision during meals and assistance with getting out of bed daily. Staff interviews confirmed that the resident was not consistently offered assistance to get out of bed and was left to eat alone, contrary to the care plan. This lack of supervision and assistance could lead to further health complications and a decline in the resident's condition.
Delayed Meal Service Due to Staffing Issues
Penalty
Summary
The facility did not ensure that each resident received at least three meals daily at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plans of care. Specifically, meal trays were delivered to nursing floors up to 1 hour and 25 minutes after the scheduled mealtimes. The facility's policy on meal service, revised in April 2022, documented that meals would be delivered promptly to assure quality. However, observations on both the North and South Units showed significant delays in meal delivery times, with breakfast carts arriving much later than the scheduled times on multiple occasions. Interviews with residents and staff revealed that the delays were due to the kitchen being short-staffed. A resident mentioned that meals sometimes came late because of staffing issues in the kitchen. Licensed practical nurses and diet technicians confirmed that meals were often late and that the nursing units were not informed of these delays. The Food Service Director acknowledged the staffing issues and stated that they had been told it was acceptable for the North Unit to be served later than scheduled. The registered dietitian, who worked remotely, did not provide oversight to the foodservice staff, further contributing to the issue. The facility failed to adhere to its posted mealtime schedule, resulting in residents receiving their meals late.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in deficiencies for two residents and a lack of a water management plan to reduce the risk of Legionella. Specifically, staff did not adhere to required personal protective equipment (PPE) protocols for residents on transmission-based and enhanced barrier precautions. Resident #45, who had pneumonia and a central line catheter, was observed without proper signage or PPE outside their room. Staff members were seen entering and exiting the room without performing hand hygiene or wearing the necessary PPE, such as gowns and masks. This non-compliance was observed multiple times, indicating a systemic issue in following infection control protocols. Resident #36, who had sepsis and extended-spectrum beta-lactamase resistance, was also not properly managed under enhanced barrier precautions. Staff members were observed entering the resident's room without performing hand hygiene or wearing gowns, despite the presence of an enhanced barrier precaution sign. The staff's lack of awareness and adherence to the required precautions further highlighted the facility's failure to implement an effective infection control program. Additionally, the facility did not have a comprehensive water management plan to address the risk of Legionella. The facility's testing in 2022 and 2023 showed inconsistencies, with one positive result in 2022 and two samples rejected in 2023 without clear documentation. The facility's inability to provide a proper water management plan and the lack of follow-up on the rejected samples, especially the one from the same location as the positive result, demonstrated a significant oversight in maintaining a safe environment for residents and staff.
Food Service 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. During the recertification survey, several deficiencies were observed, including disrepair and unclean surfaces in the kitchen. The walk-in cooler and freezer doors were broken and could not close completely, leading to frost and puddles of liquid inside. The cooler floor tiles were cracked and covered with loose rubber mats, and there were large brown spills and food debris present. Additionally, water was dripping through a light fixture, and there were leaks over the aisles in the tray line service area, creating puddles that staff had to walk through. The facility's cleaning policy was not followed, as there was no documented evidence of a kitchen cleaning schedule. Interviews with staff revealed that the kitchen had been in disrepair for months, with issues such as a shattered cooler floor, leaking ceiling, and broken freezer door. The Food Service Director and the Administrator acknowledged the problems but lacked documentation for planned repairs. The kitchen was supposed to be cleaned daily, but this was not documented, contributing to an unsafe and unsanitary environment.
Refrigerator Temperature Maintenance Failure
Penalty
Summary
The facility failed to maintain equipment in safe operating condition, specifically regarding the unit kitchenette refrigerators on both the South and North Units. On the South Unit, an upright refrigerator was labeled as out of order and had an internal temperature of 65 degrees Fahrenheit, while the freezer contained frozen food items. A small black refrigerator on the same unit had a door that did not seal properly, resulting in a measured temperature of 41.7 degrees Fahrenheit. On the North Unit, the refrigerator's thermometer read 58 degrees Fahrenheit, and it contained various food items, including cottage cheese, pureed food, tuna sandwiches, and thickened beverages. Despite the temperature log indicating a temperature of 36 degrees Fahrenheit, the actual temperature was significantly higher, suggesting a discrepancy in the recorded data. Interviews with staff revealed that the Food Service Director was aware of the temperature issues and had ordered a replacement refrigerator for the South Unit, which was redirected to the North Unit when its refrigerator also failed to maintain the proper temperature. The Director of Housekeeping and Laundry was uncertain if a maintenance request form had been completed for the faulty refrigerator. Despite the facility's protocol of checking refrigerator temperatures twice daily, documentation regarding the temperature logs and the South Unit refrigerator was not provided when requested by the surveyors. This lack of documentation and failure to maintain proper refrigerator temperatures led to the deficiency noted in the survey.
Failure to Schedule Nephrology Follow-Up for Resident with Chronic Kidney Disease
Penalty
Summary
The facility failed to ensure that Resident #60 received treatment and care in accordance with professional standards of practice. Resident #60, who was admitted with chronic kidney disease and acute kidney failure, had a recommendation for a follow-up appointment with a nephrologist within one week of discharge from the hospital. Despite multiple documented notes from the physician assistant and interdisciplinary team meetings indicating the need for a nephrology consult, there was no evidence that the follow-up appointment was scheduled or occurred. The resident expressed frustration over the delay and dissatisfaction with their renal diet, which could not be liberalized without nephrology consultation. The facility's process for scheduling and tracking consultations was inadequate. The registered nurse Unit Manager and the physician assistant both indicated that they expected the consults to be scheduled and followed up on, but there was no clear process for ensuring this happened. The Consultation Tracker showed multiple failed attempts to schedule the nephrology appointment, but there was no documented evidence that the medical provider was informed of these failures. The Director of Nursing acknowledged the issue and mentioned ongoing performance improvement audits, but the deficiency persisted. Interviews with the resident, registered nurse Unit Manager, physician assistant, and Director of Nursing revealed a lack of communication and follow-up regarding the nephrology consult. The resident's care plan included a referral to nephrology, but the necessary appointment was never secured. This failure to follow through on critical medical recommendations resulted in a significant gap in the resident's care, highlighting deficiencies in the facility's processes for managing and tracking specialist consultations.
Failure to Ensure Adequate Supervision and Hazard-Free Environment
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for two residents, leading to deficiencies in care. Resident #379, who had legal blindness and a history of falls, was found with their bed not in the low position and their call bell out of reach on multiple occasions. Despite care plan interventions specifying the need for a low bed and accessible call bell, staff failed to consistently implement these measures. Observations revealed that the resident's bed was often at hip or mid-thigh height, and the call bell was sometimes on the floor, posing a significant fall risk. Interviews with staff indicated a lack of awareness and adherence to the care plan requirements for this resident, highlighting a gap in communication and training regarding fall prevention protocols. Resident #42, diagnosed with dementia and glaucoma, was observed wandering unsupervised into other residents' rooms and beds. The resident's care plan did not include interventions for wandering or risk for victimization, despite their behavior posing potential safety risks. Staff interviews revealed that the resident had been found in other residents' beds and rooms, which could lead to victimization or other safety issues. The care instructions did not document the need for a wander alert device or increased supervision, and staff were unaware of any specific interventions for this resident's wandering behavior. The lack of appropriate monitoring and care plan updates for Resident #42 further demonstrated the facility's failure to provide a safe environment. The facility's policies on falls management and behavior management were not effectively implemented for these residents. The interdisciplinary team did not adequately identify and implement necessary interventions to reduce fall risks and manage wandering behaviors. The deficiencies observed in the care of Residents #379 and #42 indicate a broader issue with the facility's adherence to its own policies and procedures, resulting in unsafe conditions for the residents.
Failure to Maintain Nutritional Status and Provide Meal Assistance
Penalty
Summary
The facility did not ensure that Resident #75 maintained acceptable parameters of nutritional status. Specifically, the resident was not weighed as ordered, did not receive fortified pudding, and was not assisted with meals as care planned. The resident had a diagnosis of severe protein-calorie malnutrition, dysphagia, and gastrostomy status. The resident's care plan included tube feedings and a mechanically altered diet, but the resident was also supposed to receive pureed solids and honey thick liquids. However, the resident's meal intakes were consistently low, and they were not provided with all the items on their meal tray, such as fortified pudding. The resident's weight was not monitored as required. The resident was weighed on admission and once more on 4/26/2024, showing a weight loss of 2.9 pounds. There were no additional documented weights after 4/26/2024, despite the requirement for weekly weights. The registered diet technician and other staff acknowledged the missing weights and the importance of monitoring the resident's nutritional status. The resident's nutritional needs were not reassessed since admission, and the resident's intake of fortified foods and other nutritional support was not adequately managed. The resident was also not assisted with meals as care planned. Observations showed that the resident's meal trays were often left untouched, and staff did not assist the resident with eating. The care plan documented that the resident was dependent on one person for eating, but staff did not consistently provide the necessary assistance. Interviews with staff revealed that there was a lack of communication and adherence to the care plan, resulting in the resident not receiving the required support during meals.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that a resident's ability to safely self-administer medications was clinically appropriate. Specifically, Resident #45, who had end-stage renal disease and was dependent on hemodialysis, was found with a tube of lidocaine-prilocaine cream at their bedside. There was no documented evidence that the resident was assessed for their ability to self-administer this medication. The facility's policy required an assessment of a resident's mental and physical abilities to determine if self-administration was appropriate, and if not, medications were to be administered by a nurse. However, this assessment was not conducted for Resident #45. Observations during the survey revealed that the resident applied the cream to their dialysis access site before and sometimes after dialysis sessions, with the knowledge of the facility staff. Despite this, there was no physician order for the cream or instructions for self-administration. Interviews with facility staff, including a certified nurse aide and a licensed practical nurse, indicated that medications should not be kept at the bedside without a physician order, and the cream should have been stored in the medication cart. The Regional Registered Nurse confirmed that no order existed for Resident #45 to self-administer medications, and the cream should have been removed from the resident's room.
Failure to Address Language Barrier and Victimization Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a language barrier and potential risk of victimization. The resident, diagnosed with dementia and depression, had a documented need for an interpreter as their preferred language was not English. Despite this, the comprehensive care plan did not include specific interventions for the resident's language barrier or their potential to become a victim of verbal or physical abuse. Observations and interviews revealed that staff were not equipped with the necessary tools or information to effectively communicate with the resident, leading to frustration and aggressive behavior from the resident. During the survey, it was observed that the resident attempted to communicate with staff and other residents but was not understood due to the language barrier. The resident was seen trying to stand unassisted and was harshly yelled at by another resident, with no staff present to intervene. Interviews with staff indicated a lack of awareness and availability of communication tools such as picture charts or telephone translator services, which were supposed to be part of the resident's care plan. Staff members admitted to using gestures and simple language to communicate but were unaware of any specific interventions for the resident's communication needs. The facility's policies on translation services, resident rights, and behavior management were not effectively implemented for this resident. The lack of a comprehensive care plan addressing the resident's language barrier and potential victimization risk resulted in unmet needs and increased frustration for the resident. Staff interviews highlighted the importance of communication tools, yet these were not consistently available or utilized, further exacerbating the resident's communication challenges and behavioral issues.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide ongoing programs to support residents in their choice of activities, as evidenced by the cases of two residents. Resident #13, who has depression and a left lower leg amputation, was not offered meaningful activities of their choosing. Despite having a care plan that included interests such as music, Bingo, and pet therapy, the resident was not engaged in these activities. Observations and interviews revealed that Resident #13 often stayed in bed due to discomfort from their chair and was not provided with in-room activities. The Activities Director acknowledged that one-to-one room visits were lacking, and the resident's refusals to participate in activities were not adequately addressed or care planned. Resident #36, diagnosed with metabolic encephalopathy and dementia, was also not provided with activities that matched their preferences. The resident was observed sitting in the hallway for extended periods without staff interaction or activities being offered. Although the care plan included interests such as music and animals, these were not reflected in the resident's daily routine. The Activities Director admitted that the resident's care plan did not document a family interview and that one-to-one visits were insufficient. The daily chronicle provided to the resident was not effectively utilized, as the resident required assistance to engage with the activities included. Overall, the facility's failure to implement individualized activity programs for these residents highlights a deficiency in meeting the physical, mental, and psychosocial well-being of its residents. The lack of meaningful engagement and the absence of tailored interventions for residents who refuse or are unable to participate in group activities contributed to this deficiency.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident requiring such services, as observed during a recertification survey. The resident, diagnosed with end-stage renal disease and dependent on renal dialysis, had a physician's order to remove the dialysis access site dressing 6-8 hours after dialysis. However, the dressing was not removed as scheduled, and the resident reported having to remove it themselves before their next dialysis session. The facility did not have documented evidence of a hemodialysis agreement or policy and procedures, and initially claimed they had no residents receiving dialysis. Observations and interviews revealed that the resident's fistula access site was not monitored or the dressing removed by nursing staff as ordered. The resident stated that nursing staff rarely checked their fistula and never removed the dressing, leading them to do it themselves. On multiple occasions, the resident was seen with a dressing fully covering their left upper arm, indicating that the dressing had not been removed as per the physician's order. The Treatment Administration Record documented the dressing removal order, but it was not followed, and the resident was marked as out of the facility during the scheduled dressing removal time. Interviews with nursing staff and a regional registered nurse confirmed the oversight. The LPN responsible for the resident's care stated they monitored the access site but did not realize the dressing was still in place. The regional registered nurse emphasized the importance of removing the dressing as ordered to properly monitor the access site for complications and signs of infection. The failure to adhere to the physician's order and monitor the dialysis access site appropriately led to the deficiency identified during the survey.
Improper Labeling and Storage of Medications
Penalty
Summary
During a recertification survey, it was observed that the facility failed to ensure proper labeling and storage of drugs and biologicals in accordance with accepted professional principles. Specifically, on the South unit's medication cart #2, an insulin lispro pen for one resident, an insulin glargine pen for another resident, and an Anoro Ellipta inhaler for a third resident were found without opened or expiration dates. This lack of labeling could potentially compromise the effectiveness of the medications, as insulin is known to expire 28 days after opening, and the inhaler expires 6 weeks after being opened. Licensed Practical Nurse #31 acknowledged the oversight, stating that the nurse who opens the medication is responsible for dating it, and that insulin should be checked for expiration before administration. Registered Nurse Unit Manager #5 confirmed that cart audits are conducted monthly to check for expired medications and reiterated the importance of dating insulin pens. However, there was uncertainty regarding the need for dating inhalers, which was later clarified by a pharmacist who informed that the Anoro Ellipta inhaler expires 6 weeks after opening.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable, flavorful, and appetizing, as evidenced by the findings during the recertification survey. On two separate occasions, test trays revealed that food items were served at temperatures below the facility's standards. On the first occasion, beef stew was served at 114 degrees Fahrenheit and a green and yellow bean mix at 108 degrees Fahrenheit, both below the required 140 degrees Fahrenheit. On the second occasion, French-fried potatoes were found to be cold and undercooked, and other food items were also below the appropriate serving temperatures. Interviews and observations indicated that the facility's meal service policy, which required meals to be served promptly to maintain adequate temperature and appearance, was not adhered to. The Food Service Director acknowledged the temperature discrepancies and noted the absence of plate warmers as a contributing factor. Additionally, the facility failed to provide documentation of test trays when requested, indicating a lack of proper monitoring and record-keeping. A resident had previously complained about cold food, further highlighting the issue.
Failure to Provide Diet Consistent with Resident's Needs
Penalty
Summary
The facility failed to provide a diet in a form designed to meet the individual needs of a resident, specifically Resident #33, during a recertification survey. The resident, who had diagnoses including dementia, diabetes, and cervicalgia, was supposed to receive a controlled carbohydrate, mechanical soft texture diet with thin liquids as per the physician's order. However, during an observation, the resident was served a lunch tray that contained beef stew with chunks of beef larger than one inch, which was inconsistent with the mechanical soft diet requirement. The facility's menu extension sheets specified that the mechanical soft beef stew should be ground with no peas, but this was not followed. Interviews with staff revealed a lack of adherence to the facility's policy on modified food consistency. Certified Nurse Aide #15 admitted to not checking the tray and ticket for every resident, while the Supervisor #36 acknowledged that the beef stew prepared for the resident was intended for a regular diet, not a mechanical soft diet. The Food Service Director confirmed that kitchen staff were responsible for ensuring the correct consistency of meals, and the Speech Language Pathologist emphasized the importance of providing the correct food consistency to prevent complications such as aspiration, weight loss, and malnutrition.
Resident Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that Resident #35 had a means of directly contacting staff for assistance, as their call bell was consistently found to be out of reach. This deficiency was identified during a recertification survey conducted from May 6 to May 10, 2024. The facility's policy, revised in August 2019, emphasized the importance of timely response to call bells to ensure high-quality resident outcomes. Resident #35, who had moderately impaired cognition and was dependent on staff for various activities, was observed multiple times with their call bell on the floor and out of reach, despite their comprehensive care plan indicating the need for the call bell to be within reach to mitigate fall risks. Interviews with facility staff, including a certified nurse aide, a licensed practical nurse, and a registered nurse unit manager, confirmed that call bells should be within residents' reach to allow them to communicate their needs or potential emergencies. The staff acknowledged that Resident #35 was capable of using the call bell and that it was crucial for it to be accessible. The repeated observations of the call bell being out of reach highlighted a failure in adhering to the facility's policy and ensuring the resident's safety and ability to communicate needs.
Pest Control Deficiency in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in evidence of mice in a resident room. The third-party pest control vendor had previously treated the room for mice and rodents on multiple occasions earlier in the year. However, during the recertification survey, a resident reported recent sightings of mice in their room, including one that emerged from the heater and ran into the hall. The resident's roommate confirmed these sightings. Upon inspection, the Director of Housekeeping and Laundry found rodent droppings and chewed candy wrappers inside the heater unit in the resident's room. The heater had an open hole in its casing, allowing pests to enter and exit. The exterior of the heater was also observed to have metal slats with gaps, providing no barrier against pests. The Administrator acknowledged that both housekeeping and maintenance were responsible for pest management and emphasized the importance of keeping the facility free of pests to prevent disease spread.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 210 citations issued within 25 miles in the last 12 months — including the 6 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 Minoa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunnyside Care Center | 2.9 mi | ★★★★★ | 14 | 0 |
| Jewish Home Of Central New York | 4.9 mi | ★★★★★ | 19 | 0 |
| Nottingham R H C F | 6.6 mi | ★★★★★ | 7 | 0 |
| The Grand Rehabilitation And Nrsg At Chittenango | 6.8 mi | ★★★★★ | 18 | 0 |
| Bishop Rehabilitation And Nursing Center | 7.2 mi | ★★★★★ | 6 | 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.