Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Pontiac Nursing Home during CMS and state inspections, most recent first.
Improper food cooling, storage, hot holding, and sanitation were observed in the kitchen and nourishment areas. Multiple salads remained above required cooling temperatures after 2 hours, raw eggs were stored above ready-to-eat beverages, and a steam table bay was used with food held below proper hot-holding temperatures. Surveyors also found milk spills in the walk-in cooler and a dirty nourishment room with stagnant water, a plumbing leak, food debris, and other unsanitary conditions.
A resident with diagnoses including polyneuropathy, hypothyroidism, and HTN was documented at times as alert, oriented, and able to make their own care decisions, yet the facility involved the resident’s parents in financial matters and told the resident they could not use another resident’s cellphone even with permission. In addition, 12 residents reported they were not allowed to go outside alone, including into the fenced outdoor area, and staff confirmed alert and oriented residents were restricted from going out by themselves because of liability or facility policy.
Incomplete care plans failed to reflect assessed needs for several residents. A resident with bed rails had no care plan entry for their use, another resident with an indwelling urinary catheter had no comprehensive catheter care plan, and a resident with anxiety, IDD, and DM had no care plan for behaviors or insulin use despite repeated behavioral episodes and daily insulin orders. Staff interviews confirmed the care plans were incomplete and not consistently reviewed or updated.
Late insulin administration and improper pen use: Two residents with diabetes received long-acting insulin more than 3 hours past the scheduled time, and an LPN did not prime the insulin pen needles before giving the doses. One resident reported meds were often given late, and the other had a care plan for unstable BG levels. No provider notification was documented for the delayed insulin doses.
A resident with pneumonia, dysphagia, ALS, severe cognitive impairment, and tube feeding had a respiratory decline with labored breathing and oxygen use, but the LPN did not document the change in condition, obtain or record orders for oxygen or a chest x-ray, or clearly notify the RN supervisor, provider, or family. The chest x-ray showed left base consolidation, but the result was not relayed to the provider until 2 days later, and there were no documented vital signs for an extended period before the resident died.
A resident with pneumonia and a new order for nectar/mildly thick liquids was repeatedly given or accessed thin liquids, including soda and hot cocoa that was not consistently thickened. Staff noted the resident was unhappy with the diet, sometimes non-compliant, and there was no SLP referral for the new diet until later. CNA records also conflicted with the ordered liquid consistency, and the only intervention described was education.
Two residents did not maintain acceptable nutritional status. One resident with stroke, dysphagia, and a G-tube was self-administering TF without a physician order or documented competency evaluation, received the wrong formula in the room, and had orders that did not match the dietitian’s calorie and free-water recommendations. Another resident with dementia and failure to thrive had significant ongoing wt loss, but follow-up nutrition assessments were not documented after the initial recommendation for Ensure Plus, and the resident was served Ensure Clear despite preferring Ensure Plus.
A resident was observed using CPAP therapy without a physician order, documented diagnosis, care plan, or cleaning and maintenance orders. Staff reported the machine came from the group home, was being applied at night, and that the resident did not have a sleep apnea diagnosis; the mask was also observed with brown stains and staff were unsure whether the mask or tubing had ever been cleaned.
Food was not consistently palatable or appetizing at lunch when a resident received a soggy grilled cheese sandwich and then a replacement sandwich that was burnt on both sides. Staff stated the sandwiches had been grilled 45 minutes before service, and there was no documented evidence of a food palatability or meal test tray policy.
A resident with DM, PVD, and bilateral lower leg wounds had repeated wound NP recommendations for an ABI before Unna boot use because arterial/venous status was unknown. Staff documented the wound notes but there was no evidence the ABI was ordered or completed, and the DON stated they were unaware of the need for the study.
Failure to Follow Contact Precautions: A resident on contact precautions for shingles, with a gastrostomy tube and chronic back ulcer, was observed receiving room care from a housekeeper and CNA who entered without gown or gloves and left without hand hygiene. The facility policy required PPE and hand hygiene for contact precautions, but both staff members stated they did not see the precaution sign when they entered the room.
Late MDS Quarterly Assessments for Two Residents: The facility did not complete quarterly MDS assessments for two residents on time. Record review showed both residents had overdue MDSs, and the DON stated they should have been completed earlier but were missed, possibly during the transition to a new electronic system. The MDS Coordinator said the schedule was being tracked on a spreadsheet while the facility was using both systems.
Improper food cooling, storage, hot holding, and sanitation
Penalty
Summary
Food was not prepared, stored, distributed, and served in accordance with professional standards during the survey. The facility’s Cooling Log Sheet required foods to be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours, but macaroni salad and pasta salad were documented on multiple dates as remaining between 73 and 78 degrees Fahrenheit after 2 hours of cooling. No corrective actions were documented for those entries, and the Food Service Director stated the items should have been discarded and the process restarted when temperatures remained above 70 degrees Fahrenheit. Food storage and hot holding practices were also observed to be out of compliance. In the activities room refrigerator, a dozen raw eggs were stored directly above a drawer containing bottles of pop, and the Rehab Director stated they were not aware of the storage requirements. During meal service, food on the first-floor dining tray line steam table included tomato soup at 156 degrees Fahrenheit, grilled cheese sandwiches at 130 degrees Fahrenheit, and a fourth bay containing gravy at 90 degrees Fahrenheit, mashed potatoes at 108 degrees Fahrenheit, and riblets at 122 degrees Fahrenheit. Staff stated the bay was not turned on and should not have been used for service if it was not heated properly. Sanitation issues were also observed in food storage and nourishment areas. The walk-in cooler had white spills and a significant amount of liquid milk on the floor beneath the shelving over several observations, with the milk tracked across the cooler floor. The second-floor nourishments room contained stagnant brown water in a pitcher under the sink, a plumbing leak, dried brown liquid in the cupboard, a hole in the back wall, a stained bed sheet under the sink, and food debris and spills around the sink and refrigerator. The Environmental Services Director and Food Service Director stated the areas should have been clean and free of leaks, spills, and debris.
Resident autonomy and outdoor access restrictions
Penalty
Summary
The facility did not ensure one resident’s right to a dignified existence and self-determination when it involved the resident’s family in financial decisions without first asking the resident, despite documentation showing the resident had intact decision-making ability at times and was alert, oriented, and able to make their own care decisions. The resident had diagnoses including polyneuropathy, hypothyroidism, and hypertension, and records noted moderate cognitive impairment on one assessment, but later progress notes documented good judgment and normal recent and remote memory. The resident reported that the facility told their parents about the resident’s online shopping and forwarded the resident’s debit card to the parents, and that the resident was told they could not use another resident’s cellphone even though that resident had given permission. Facility documentation showed staff became concerned about the resident’s online purchases and unpaid credit card debt, and a social worker contacted the resident’s parents because of the resident’s history of buying items they did not use. A meeting was held with the resident and the parents, after which the resident gave the parents their debit card and received a monthly spending amount. During interview, the social worker stated the resident was alert and oriented and could make their own care decisions, but the facility involved the parents when the resident was ordering too many packages and when the resident used another resident’s cellphone. The resident stated they were unhappy that staff emailed the parents and told them the resident was not allowed to use another resident’s cellphone per facility policy. The facility also did not allow residents to go outside by themselves, including into the fenced-in outdoor areas, and 12 of 12 residents at a resident meeting stated they were not allowed to do so even if they were alert and oriented. Resident council minutes documented requests for increased outdoor access, but there was no documented follow-up from the Administrator. Staff interviews confirmed that alert and oriented residents were not permitted to go outside alone because of liability or facility policy, and that the patio doors were locked and alarmed, with access unlocked only for families or when a resident had a provider pass order.
Incomplete Care Plans for Bed Rails, Catheter, Behaviors, and Diabetes
Penalty
Summary
The facility did not develop and implement a comprehensive person-centered care plan to meet residents’ medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for four residents reviewed. The facility policy stated care plans were to be initiated on admission and reviewed quarterly after MDS completion, with updates as needed. However, the record review and interviews showed that the care plans for Residents #6, #21, #41, and #44 were incomplete or not updated to reflect assessed needs and current care requirements. Resident #6 had diagnoses including morbid obesity and epilepsy, and the 4/26/2025 MDS documented moderate cognitive impairment, moderate assistance for bed mobility, and no use of bed rails. During an observation on 9/8/2025, the resident had bilateral enabler bars on the bed and stated they used them when rolling in bed. The care plan addressed weakness and anxiety with limited assistance for bed mobility and encouragement to participate, but there was no documented evidence of the use of bed rails. Staff interviews indicated uncertainty about whether the resident had bed rails and where that information should appear in the care plan. Resident #44 had diagnoses including urinary retention, COPD, and hypertension. The 8/18/2025 MDS documented that the resident was cognitively intact, had no behaviors, and had an indwelling urinary catheter, and the CAA summary triggered the catheter and was addressed in the care plan. The physician order required changing the urinary drainage device every 30 days, but there was no documented evidence of a comprehensive care plan related to the urinary catheter. Resident #21 had diagnoses including anxiety, intellectual disabilities, and diabetes. The 6/14/2025 MDS documented moderate cognitive impairment and daily insulin injections, antipsychotics, antianxiety medication, and antidepressants. Although the CAA summary triggered behavioral symptoms, the comprehensive care plan did not address behaviors, diabetes, or insulin administration. Nursing notes and observations documented repeated behavioral episodes, including refusal of medications, throwing items, yelling, entering the nurses’ station, and demanding a pen, while staff interviews confirmed the resident had behaviors and should have care planned interventions, but the care plan did not contain them.
Late insulin administration and improper pen use
Penalty
Summary
The facility failed to ensure medication services met professional standards of quality for two residents with diabetes, Resident #13 and Resident #41. There was no documented facility policy on medication administration or insulin administration, and there was no documented comprehensive care plan addressing Resident #13’s diabetes or insulin administration. Resident #13 had diagnoses including diabetes, intact cognition, and did not receive daily insulin injections per the 8/5/2025 MDS. During an interview, the resident stated medications, including insulin, were often not given until 10:00 AM or 11:00 AM even though they were supposed to be given before breakfast, and they had incidents of high blood sugars. On 9/10/2025, LPN #5 administered Resident #13’s Basaglar Kwik Pen at 11:06 AM even though the MAR scheduled it for 8:00 AM, and the insulin pen was not primed before the dose was dialed in. The resident asked for a glucose check before administration, and the finger stick was 206. There was no documented evidence the provider was contacted about the delay. The same day, LPN #5 administered Resident #41’s Lantus Solostar scheduled for 8:00 AM at 11:22 AM, giving 60 units, changing the needle, and giving another 60 units to equal 120 units, without priming the needles before dialing in the doses. Resident #41 had diabetes, intact cognition, daily insulin injections, and a care plan noting unstable blood glucose levels with an intervention to administer medications as prescribed. There was no documented evidence the provider was contacted about the delay, and the LPN stated they had not been taught to prime pen needles and did not notify the provider about the late insulin administration.
Delayed assessment and communication for resident with respiratory decline
Penalty
Summary
The facility did not ensure Resident #20 received care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan when the resident had a change in condition and was not assessed timely by a qualified professional. Resident #20 had diagnoses including pneumonia, dysphagia, and amyotrophic lateral sclerosis, was severely cognitively impaired, non-verbal, tube fed, and not previously on oxygen. The care plan documented the resident was non-verbal and used a white board, nodding, or thumbs up/down to communicate. During the survey, the resident was observed with labored breathing and oxygen in use, but there was no documented physician order for oxygen therapy, no nursing note explaining why oxygen was started, and no registered nurse assessment from admission through 9/10/2025. On 9/8/2025, Licensed Practical Nurse #25 stated the resident had a change in condition, with death breathing, oxygen saturation of 91% on room air, and respirations of 30. The LPN said they texted Nurse Practitioner #9 and were instructed to start oxygen at 2 liters via nasal cannula and obtain a chest x-ray. However, there was no documented evidence of orders received for oxygen or the chest x-ray, and the LPN did not document the change in condition or notify the medical professional and family in the record. The resident’s family was reportedly at the bedside, but there was no documented notification attempt. A chest x-ray was performed and the report showed minor left base consolidation that could be atelectasis or pneumonia. The report was received by the facility at 3:30 PM on 9/8/2025, but there was no documented evidence the provider was notified at that time. Registered Nurse Supervisor #4 stated they were not notified of the change in condition on 9/8/2025 and did not assess the resident until 9/10/2025, when they called the Medical Director with the radiology results. The Medical Director was then told about the resident’s condition and advised continued monitoring. There were no documented vital signs from 8/29/2025 through 9/10/2025, and the resident died on 9/10/2025 at 11:50 PM.
Failure to Maintain Ordered Thickened Liquids and Address Non-Compliance
Penalty
Summary
The facility did not ensure the resident environment remained free of accident hazards for one resident who had a physician order for nectar/mildly thick liquids. Resident #41 had diagnoses including bacterial pneumonia, schizoaffective disorder bipolar type, and hypertension, and the 4/8/2025 MDS documented the resident was alert and oriented, required set up for eating, and had no swallowing disorders. After returning from the hospital on 8/25/2025 with a discharge summary noting soft and bite size solids with nectar thick liquids and swallowing difficulties, the resident was also documented on a physician order for carbohydrate controlled diet with soft bite sized solids and nectar/mildly thick consistency. The resident was observed being given thin liquids despite the ordered consistency. On 9/8/2025, the resident asked for soda, and staff told the resident they needed to stick to their liquid consistency; staff initially did not have thickener packets available, and the resident stated they had had soda the prior nights. RN #8 later found thickener packets and thickened the soda. On 9/9/2025, the resident had a bottle of soda at the dining room table, and RN Supervisor #4 stated the resident was on nectar thick liquids but would not give the soda up. The resident was also provided hot cocoa that was thin when stirred; staff later stated it had been thickened, but the Food Services Director acknowledged only one packet of thickener had been added to an 8-ounce cocoa even though the packet was intended for 4 ounces. The record also showed the resident was unhappy with the thickened liquid diet and was sometimes non-compliant, but there was no documented evidence of a speech-language pathology referral for the new diet until 9/9/2025. CNA accountability records listed the resident on regular solids and thin liquids, which conflicted with the hospital discharge summary and physician order. Staff interviews stated the resident would go to the vending machine for soda, sometimes allowed staff to thicken it, and was not very compliant with the ordered liquid consistency. The only intervention described for refusals was education, and the DON stated the resident should have had a care plan related to non-compliance when it became known to staff.
Failure to Maintain Adequate Nutrition and Tube Feeding Orders
Penalty
Summary
The facility did not ensure two residents maintained acceptable nutritional status. One resident with stroke and dysphagia had a gastrostomy tube and was dependent for eating, with the 8/1/2025 MDS documenting moderately impaired cognition, significant weight loss, and that more than half of daily calories were received through tube feeding. The resident’s care plan addressed dysphagia, and the physician order changed from Osmolite 1.5 with free water flushes to Osmolite 1.2 four times daily via gravity bolus, but the new order did not include water flushes or permission for self-administration. The resident’s room contained Osmolite 1.5, while the MAR reflected Osmolite 1.2, and staff observed the resident self-administering the feeding without documented evaluation of physical or mental ability, without documented teaching, and without a physician order authorizing self-administration. The dietitian’s assessment documented that the resident’s ordered tube feeding was below estimated needs and recommended a higher-calorie regimen, but the resident’s weights showed a decline from 168 pounds to 160.3 pounds, a 5% loss in one month. The report states there was no documented evidence that the tube feeding volume or water flushes were adjusted to meet estimated nutritional needs and weight goals. During interviews, the resident stated they sometimes only completed three of the four feedings, used more water than instructed to thin the formula, and kept the feeding supplies in the room. Nursing staff and the dietitian acknowledged that the resident was receiving the wrong formula in the room and that the order did not include the water flushes that were expected. A second resident with adult failure to thrive, dementia with agitation, and hypothyroidism had significant ongoing weight loss. The resident’s weights declined from 137 pounds in March to 117.4 pounds in July, then to 106.8 pounds in August and remained 106.8 pounds in September. The July nutrition assessment documented significant weight loss and recommended Ensure Plus twice daily, but the report states there were no documented nutritional assessments for August or September to follow up on continued weight loss or the effectiveness of interventions. Meal tickets showed Ensure Clear Apple at meals, while staff interviews indicated the resident preferred Ensure Plus and did not like the clear supplement. The dietitian stated the resident had not been followed up in August despite further weight loss and that Ensure Clear had not been recommended for the resident.
Unordered CPAP Use Without Diagnosis, Care Plan, or Cleaning Documentation
Penalty
Summary
Resident #48 received continuous positive airway pressure (CPAP) therapy without a physician order, without a documented supporting diagnosis, without a care plan addressing the device, and without documented orders for cleaning or maintenance. The resident had diagnoses including anxiety, depression, and trisomy, and the 7/29/2025 MDS documented severely impaired cognition and no respiratory treatments, including CPAP. The 7/22/2025 hospital discharge summary documented drug induced syncope with hypoxia, but there was no documentation that the resident required or used CPAP, and the comprehensive care plan did not include CPAP use. The admission assessment documented that the resident had a CPAP machine from the group home, but there were no hospital orders for it and staff planned to contact the group home for settings. The medical director’s H&P and multiple NP encounter summaries did not document a diagnosis supporting CPAP use. A nurse note documented the resident was awake most of the night and the CPAP machine was on with short term effects, and the September 2025 vital sign summary showed oxygen saturation measurements taken while the resident was on CPAP on multiple nights. During observations, the resident was seen sleeping with the nasal mask on and the machine running, with the water reservoir about half full. On another observation, the mask was on the floor and had brown stains on the gray fabric, and a CNA stated they were not sure if the mask or tubing had ever been cleaned. Staff interviews confirmed the machine was being applied and used without an order, that the resident did not have a diagnosis of sleep apnea, that the resident needed help to place the mask, and that no one had obtained the required order or documented settings for the device.
Food Served at Improper Temperature and Poor Quality
Penalty
Summary
The facility did not ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for one of two meals reviewed, specifically the lunch meal. During observation, a resident's meal tray was tested and a replacement tray was ordered because the grilled cheese sandwich was soft and had a soggy texture. When the replacement grilled cheese sandwich was delivered, it was black in color on both sides, with one side darker than the other. The Food Service Director stated the grilled cheese sandwiches for the lunch meal were grilled 45 minutes ahead of service, and a staff member stated they would not allow food to leave the kitchen if it did not look good, adding that the burnt grilled cheese sandwiches should not have been served to residents. The report also states there was no documented evidence of a food palatability or meal test tray policy.
Failure to Obtain Recommended ABI Study
Penalty
Summary
The facility failed to obtain outside professional services for a resident when a qualified professional was not employed to provide the needed service. Resident #13 had diabetes, peripheral vascular disease, intact cognition, and two non-pressure-related skin ulcers. The resident’s wound care plan addressed wound management, and the wound nurse practitioner documented bilateral lower leg skin issues with maceration, blue/green drainage, heavy drainage soaking through wraps and into shoes, and the resident’s statement that they could not feel their legs. The wound nurse practitioner repeatedly recommended an ankle-brachial index (ABI) test before Unna boot application because arterial and venous status was unknown. Despite repeated weekly wound notes stating that no ABI was on file and that the ABI had been requested at prior visits, there was no documented evidence that the ABI was ordered or completed. Facility staff stated they uploaded the wound nurse practitioner’s notes, entered brief progress note summaries, and handled consults through scheduling, but the resident did not have an order for a vascular workup or ABI study. The wound nurse practitioner stated they had emailed staff and the DON/Administrator about the lack of follow-up and believed the delay in obtaining the ABI meant they had been doing what they could rather than the treatment they wanted to provide.
Failure to Follow Contact Precautions
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 for one resident on contact precautions. Resident #55 had diagnoses including a gastrostomy feeding tube and a chronic back ulcer, and had a physician's order dated 9/9/2025 for contact precautions for shingles. The facility policy for isolation and transmission-based precautions required standard precautions and, when contact precautions were indicated, clean gloves and a disposable gown to be worn when entering the room, with removal of the gown and gloves and hand hygiene performed before exiting. During observation, Housekeeper #22 was sweeping in Resident #55's room without a gown or gloves and did not perform hand hygiene before leaving the room. Housekeeper #22 stated they were unsure whether PPE was required and said they should have worn a gown and gloves after reading the precaution signs, but did not see the sign on the wall next to the door when entering. During another observation, Certified Nurse Aide #23 entered the room without a gown or gloves, was reminded by another CNA that the room was under contact precautions, provided ice to the resident, and exited without performing hand hygiene. The CNA stated they were supposed to wear a gown and gloves in a contact precaution room but did not see the sign when entering to answer the resident's call light.
Late MDS Quarterly Assessments for Two Residents
Penalty
Summary
The facility did not ensure that residents were assessed with the quarterly review instrument at least once every three months for two of four residents reviewed, Residents #25 and #52. Record review showed that Resident #52's MDS assessment had an ARD of 5/10/2025 and was not completed, and Resident #25's MDS assessment had an ARD of 5/5/2025 and was not completed. The report also noted there was no documented evidence of an MDS assessment policy. During a telephone interview, the MDS Coordinator stated the facility tracked the MDS schedule on a spreadsheet while transitioning to a new electronic system and that they were not at the facility and could not access the electronic system until later that day. The DON stated that both residents' quarterly MDS assessments were overdue and should have been completed in early August 2025, but they were not completed, and the DON was unsure why they were missed, stating they may have been missed during the transition to the new electronic system.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 13 citations issued within 25 miles in the last 12 months — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oswego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Luke Residential Health Care Facility Inc | 0.1 mi | ★★★★★ | 0 | 0 |
| Morningstar Residential Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Seneca Hill Manor Inc | 3.6 mi | ★★★★★ | 1 | 0 |
| Syracuse Home Association | 22 mi | ★★★★★ | 12 | 0 |
| The Cottages At Garden Grove, A Skilled Nrsg Comm | 25 mi | ★★★★★ | 4 | 0 |
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