Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Presbyterian Home For Central New York Inc during CMS and state inspections, most recent first.
A resident with dementia and a history of wandering exited the building by removing a window panel and was found in a fenced courtyard. Despite being assessed as high risk for elopement and wearing a wander alert bracelet, the incident was not reported to the state agency as required, as staff believed it was not necessary since the resident remained on facility property.
The facility failed to ensure proper procedures for the use and storage of food brought in by visitors, leading to undated food items in refrigerators and staff uncertainty about reheating temperatures. Staff interviews revealed a lack of training and knowledge regarding the correct procedures, and the facility's policy did not include recommended reheating temperatures.
The facility failed to maintain an effective infection prevention and control program, leading to deficiencies in the care of seven residents. Staff did not consistently use PPE or perform hand hygiene, and residents with infections or indwelling medical devices were not placed on appropriate precautions.
A resident with diabetes was found with glucose tablets at their bedside without an assessment or physician order for self-administration. The resident had moderately impaired cognition and required assistance with daily activities. Staff interviews confirmed that medications were not allowed in resident rooms without an order, and the presence of glucose tablets posed a risk to the resident and others.
The facility failed to update care plans for two residents, one with frequent urinary tract infections and another with a wandering risk due to dementia. Despite documented medical issues and observations of wandering behavior, the care plans were not revised, leaving staff without necessary information to provide proper care.
The facility failed to update the care plan and meal tickets for a resident after their 2,000 milliliter fluid restriction was discontinued by the medical provider. Despite staff being aware of the change, the meal tickets continued to list the restriction, and the resident was provided ice with their soda. This discrepancy posed a risk to the resident's health, highlighting a communication breakdown in updating dietary orders.
A resident with dementia, rheumatoid arthritis, and hand contractures did not have their palm guards applied as recommended by occupational therapy. Observations showed the resident without the guards on multiple occasions, and staff interviews revealed inconsistencies in the application and monitoring of the guards, leading to potential worsening of contractures and skin breakdown.
A resident with dysphagia, dementia, and moderate protein-calorie malnutrition experienced a significant weight loss of 15.5 pounds within four days. The facility failed to reassess the resident's nutritional needs, notify the medical provider, and provide adequate staff assistance during meals, resulting in poor intake and a deficiency in maintaining the resident's health.
A facility failed to ensure a resident's head of the bed was elevated during and after enteral feedings, as required by physician orders and facility policy. Despite the resident's diagnoses and the risk of aspiration, staff did not consistently follow the protocol, increasing the risk of complications.
The facility failed to label medications with opened or expiration dates and did not maintain appropriate refrigerator temperatures, compromising the safety and effectiveness of medications administered to residents.
A resident with spinal issues and intact cognition was asked to use a bedpan instead of being taken to the toilet, causing pain and urine leakage. The CNA involved cited back pain and the nurse's inability to help, leading to undignified care. The facility's investigation confirmed the resident's account, and the CNA was no longer employed.
The facility failed to ensure necessary services for residents unable to perform activities of daily living, resulting in unclean and untrimmed fingernails for two residents and significant facial hair for another. Despite documentation indicating personal hygiene tasks were completed, interviews revealed inconsistencies in care.
Failure to Report Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to report an elopement incident involving a resident with dementia and a history of wandering to the New York State Department of Health, as required by state regulations and facility policy. The resident, who was assessed as high risk for elopement and wore a wander alert bracelet, exited the building by removing a window panel from an unoccupied room and was found standing in the fenced-in courtyard with their walker. The incident was discovered after a certified nurse aide noticed the resident was missing from the hallway and subsequently found the window panel displaced and the resident outside. The resident's medical history included unspecified dementia, impulse disorder, and a previous fracture in the same leg that was later found to be fractured again following the incident. The resident was on antipsychotic and antianxiety medications, had moderate cognitive impairment, and was known to wander. The care plan identified the resident as an elopement risk, and interventions included a wander alert bracelet and various diversions to prevent unsafe wandering. Despite these measures, the resident was able to exit the secure care unit undetected for a period of time. Facility staff, including the DON and maintenance, responded to the incident by securing the window and assessing the resident. However, the facility did not notify the state agency of the elopement, believing it was not reportable since the resident remained on facility property within a fenced area. This decision was made despite having access to the state incident reporting manual, which outlines criteria for reportable elopements, including those involving cognitively impaired residents who leave the facility undetected.
Deficiency in Food Handling and Storage Procedures
Penalty
Summary
The facility did not ensure a policy and procedure regarding the use and storage of food brought to residents from outside the facility to ensure safe and sanitary storage, handling, and consumption for two resident units. Specifically, staff were unaware of the proper procedures for reheating and measuring the temperatures of food brought in from outside. Observations revealed undated food items in the refrigerators of the Broadway and Rodeo units. Interviews with staff, including licensed practical nurses, certified nurse aides, and the Food Service Director, indicated a lack of training and knowledge regarding the proper reheating temperatures and labeling requirements for food brought in by visitors. The facility's policy did not include recommended temperatures for reheating food, contributing to the staff's uncertainty about the correct procedures. During the survey, it was observed that the Broadway kitchenette refrigerator contained an undated take-out container, and the Rodeo kitchenette refrigerator had undated containers of chicken and mixed fruit. Staff interviews revealed that they were unsure of the proper reheating temperature and had not received adequate training on the procedure. The Food Service Director and registered dietitian confirmed that nursing staff were responsible for labeling and dating food items and that food should be discarded after three days. However, the lack of specific temperature guidelines in the policy and insufficient staff training led to the observed deficiencies in food handling and storage practices.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, leading to deficiencies in the care of seven residents. Resident #17, who had clostridioides difficile, did not have timely implementation of transmission-based precautions. Observations revealed that staff did not consistently use personal protective equipment (PPE) or perform hand hygiene when entering and exiting the resident's room, increasing the risk of infection spread. The care plan for Resident #17 also lacked documentation of the necessary precautions, and staff were observed handling items without appropriate PPE or hand hygiene practices. Resident #22, who had extended-spectrum beta-lactamase in the urine, and Resident #33, who had colonized extended-spectrum beta-lactamase in the sputum, were not properly maintained on transmission-based precautions. Additionally, Residents #82 and #278, who had indwelling medical devices, and Residents #89 and #267, who had wounds, were not placed on enhanced barrier precautions as required. Staff, including licensed practical nurses and certified nurse aides, were observed not wearing gowns during high-contact activities and failing to perform hand hygiene consistently. Interviews with staff, including licensed practical nurses, registered nurses, and the Infection Preventionist, revealed a lack of understanding and implementation of enhanced barrier precautions. Staff were unsure of the requirements and the importance of hand hygiene in preventing the spread of infections. The facility's policies on enhanced barrier precautions and transmission-based precautions were not adequately followed, leading to multiple instances of non-compliance and increased risk of infection transmission among residents.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility did not ensure that a resident's ability to safely self-administer medications was clinically appropriate. Specifically, a resident with diabetes was observed with glucose tablets at their bedside without documented evidence that the interdisciplinary team had assessed their ability to self-administer the medication. The resident had moderately impaired cognition and required assistance with most activities of daily living. The comprehensive care plan indicated that the resident was unable to self-administer medications, and there was no physician order for glucose tablets or instructions for self-administration in the resident's records. During multiple observations, the glucose tablets were seen on the resident's nightstand, and staff interviews revealed that medications were not allowed in resident rooms unless there was an order for self-administration. The staff did not notice the glucose tablets in the resident's room, and it was noted that having the tablets posed a risk to the resident and others. The Director of Nursing confirmed that the resident should not have had glucose tablets at their bedside and emphasized the importance of monitoring the resident's blood sugar levels accurately to adjust medications as needed.
Failure to Update Care Plans for Residents with Urinary Tract Infections and Wandering Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan to meet the medical and nursing needs of two residents. Resident #4, who had a history of frequent urinary tract infections and chronic kidney disease, did not have an updated care plan that included interventions for their recurring urinary tract infections. Despite multiple documented instances of urinary tract infections and the administration of antibiotics, the care plan was not revised to reflect these issues, leaving staff without the necessary information to properly care for the resident. Interviews with staff revealed confusion about who was responsible for updating care plans, contributing to the oversight. Resident #32, diagnosed with dementia, did not have a care plan that addressed their wandering risk. The resident was observed independently propelling their wheelchair throughout the facility, entering other residents' rooms, and being found in various locations such as the lobby and hallways. Despite these observations and the resident's moderate cognitive impairment, the care plan did not include measures to address the wandering behavior. Staff interviews indicated a lack of awareness and specific interventions for managing the resident's wandering risk. The facility's policy required the development and implementation of comprehensive care plans to meet each resident's needs, including medical, psychosocial, and nutritional needs. However, the care plans for both residents were not updated to reflect their current conditions and risks, leading to deficiencies in their care. The lack of updated care plans meant that staff were not adequately informed about the residents' needs, which could impact the quality of care provided.
Failure to Update Care Plan and Meal Tickets After Discontinuation of Fluid Restriction
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for Resident #79 based on changing goals and needs. Despite the medical provider discontinuing the resident's 2,000 milliliter fluid restriction on 4/18/2024, the care plan and meal tickets continued to include this restriction. This discrepancy was observed on multiple occasions from 4/23/2024 to 4/25/2024, where the resident's meal tickets still documented the fluid restriction, and staff provided ice with the resident's soda despite the restriction being removed. Interviews with staff revealed that although they were aware of the discontinuation, they did not notify the appropriate personnel to update the meal tickets and care plan. Resident #79 had diagnoses including chronic kidney disease, peripheral vascular disease, and congestive heart failure. The resident had intact cognition and was capable of making decisions regarding their care. The failure to update the care plan and meal tickets after the fluid restriction was discontinued posed a risk to the resident's health. Staff interviews indicated a lack of communication and follow-through in updating the resident's dietary orders, which could lead to potential health risks such as fluid overload or exacerbation of congestive heart failure.
Failure to Apply Palm Guards for Resident with Hand Contractures
Penalty
Summary
The facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. Specifically, a resident with diagnoses including dementia, rheumatoid arthritis, and contracture of the right hand did not have their resting palm guards applied appropriately as recommended by occupational therapy for hand and finger contractures. The resident was observed on multiple occasions without the bilateral palm guards, which were supposed to be worn except during care delivery. The facility's policy on orthotic devices assured that residents received appropriate services and interventions to maintain joint range of motion and elasticity. However, the resident's care plan and occupational therapy recommendations for the use of bilateral palm guards were not consistently followed. The care card indicated that the palm guards should always be on except during care delivery, but observations showed the resident without the guards on several occasions. Interviews with staff revealed inconsistencies in the application and monitoring of the palm guards. Certified nurse aides and nurses had differing understandings of their responsibilities regarding the application of the palm guards. Some staff admitted to not applying the guards and not reporting it, while others believed it was the responsibility of the certified nurse aides. The lack of proper documentation and communication among staff contributed to the failure to ensure the resident's palm guards were applied as recommended, potentially leading to worsening contractures and skin breakdown.
Failure to Maintain Resident's Nutritional Status
Penalty
Summary
The facility did not ensure that Resident #276 maintained acceptable parameters of nutritional status, leading to a significant weight loss. The resident, who had diagnoses including dysphagia, dementia, and moderate protein-calorie malnutrition, was admitted with a diet order of regular pureed texture solids and pudding thick liquids. Despite the facility's policy requiring regular monitoring of weights and reassessment of nutritional status, the resident experienced a weight loss of 15.5 pounds (14.69%) within four days, from 105.5 pounds on 4/18/2024 to 90 pounds on 4/22/2024. There was no documented evidence that the registered dietitian reassessed the resident's nutritional needs or reviewed the nutritional plan of care following this significant weight loss. The resident's electronic medical record did not contain any weights other than the 90 pounds recorded on 4/22/2024, and there were no documented nursing notes from 4/18/2024 to 4/21/2024. Additionally, there was no evidence that the medical provider was notified of the resident's significant weight loss. Observations of the resident during meal times revealed that the resident often did not receive staff assistance or encouragement to eat, and their intake was consistently low, with fluid intake ranging from 20-600 milliliters daily and solid food intake at 25% or less for all meals. Interviews with facility staff, including the speech language pathologist, registered nurse Unit Manager, ward clerk, occupational therapist, nurse practitioner, and registered dietitian, revealed a lack of communication and follow-up regarding the resident's weight loss and poor intake. Staff were unaware of the resident's significant weight loss and did not take appropriate actions to reassess the resident's nutritional needs or notify the medical provider. The registered dietitian was not informed of the weight loss and did not review the resident's meal and fluid intakes prior to learning about the weight loss. The facility's failure to monitor and address the resident's nutritional status resulted in a deficiency in providing adequate food and fluids to maintain the resident's health.
Failure to Elevate Head of Bed During Enteral Feeding
Penalty
Summary
The facility did not ensure that a resident being fed by enteral means received the appropriate treatment and services to prevent complications such as aspiration. Specifically, the head of the bed for Resident #82 was not elevated during and after receiving enteral feedings as ordered. The facility policy required the head of the bed to be positioned at 30-45 degrees during feeding and for 30 minutes after feeding, but observations showed that the resident was lying flat on their back during these times. This was confirmed by multiple observations and interviews with staff, who acknowledged the importance of keeping the head of the bed elevated to prevent aspiration pneumonia. Resident #82 had diagnoses including adult failure to thrive, gastrostomy status, and moderate protein-calorie malnutrition. The resident was cognitively intact and on a prescribed weight gain regimen with a feeding tube. Despite the physician's orders and the facility's policy, the head of the bed was not consistently elevated as required. Licensed practical nurse #8 and other staff members admitted to not following the orders, which increased the risk of aspiration and potential hospitalization for the resident. The Director of Nursing confirmed that staff were educated on these protocols but failed to adhere to them in this instance.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility did not ensure that drugs and biologicals were labeled and stored according to professional principles. Specifically, the Wall Street medication cart had an insulin pen for a resident that was not labeled with an opened or expiration date. Additionally, the Rodeo Drive medication cart had an inhaler for another resident that was not labeled with an opened or expiration date, and the medication cart was left unattended and unlocked at the nursing station. The facility's policies required that multi-dose medications be initialed and dated when opened, and insulin pens be labeled with the resident's name, expiration date, and the date it was first opened. However, these policies were not followed, leading to the potential use of expired medications, which may not be effective in controlling the residents' conditions. The pharmacy confirmed that budesonide formoterol inhalers should be discarded three months after being removed from their foil pouch, but this was not adhered to in the facility. The facility also failed to consistently monitor and maintain the temperatures of medication refrigerators. The Wall Street medication refrigerator temperature log showed dates without readings and readings that were not within the appropriate temperature range of 36-46 degrees Fahrenheit. The Rodeo Drive medication refrigerator also had dates without temperature readings. The contents of these refrigerators included various medications that required specific storage temperatures to maintain their efficacy. The night shift nurses were responsible for checking the refrigerator temperatures, but there was no double-check system in place to ensure compliance. The registered nurse Unit Manager was unsure of the appropriate temperature range and stated that maintenance was notified if the temperature was out of range, but there was no documented maintenance notification for April 2024. The failure to label medications with opened or expiration dates and to maintain appropriate refrigerator temperatures could compromise the safety and effectiveness of the medications administered to residents. The facility's policies were not followed, and there was a lack of proper oversight and documentation to ensure that medications were stored and handled correctly. This deficiency could potentially harm residents by exposing them to expired or improperly stored medications, which may not provide the intended therapeutic effects.
Failure to Honor Resident's Dignity and Care Plan
Penalty
Summary
The facility did not treat a resident with respect and dignity, nor did it provide care in a manner that promoted the enhancement of quality of life. Specifically, a resident with diagnoses of intervertebral disc degeneration, morbid obesity, and polyneuropathy, who had intact cognition and required staff assistance for transfers and toileting, was asked to use a bedpan instead of being taken to the toilet as requested. The resident's care plan did not include the use of a bedpan, and the resident reported that using the bedpan caused them spine and low back pain, leading to urine leakage and a wet bed. The incident occurred when the resident rang their call bell during the night to use the bathroom. A certified nurse aide responded and initially assisted the resident to the toilet using a stand lift. However, when the resident needed to use the bathroom again a couple of hours later, the same certified nurse aide insisted that the resident use a bedpan, citing back pain from using the mechanical lift and stating that the nurse on duty was too old to help. The resident reluctantly agreed to use the bedpan, resulting in urine leakage and a wet bed. The certified nurse aide was reportedly abrupt and did not provide the resident with a dry nightgown after changing the bed linens. The facility's investigation confirmed the resident's account, and the certified nurse aide involved was no longer employed at the facility. Interviews with other staff members, including the Director of Nursing, confirmed that the resident should have been assisted to the toilet as per their care plan, and that the use of a bedpan was inappropriate and undignified for a continent resident who could use the toilet. The incident highlighted a failure to honor the resident's rights to dignity and appropriate care.
Deficiencies in Personal Hygiene and Grooming
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 #2 was not assisted with the removal of unwanted facial hair, Resident #12 had unclean and untrimmed fingernails, and Resident #35 had unclean fingernails. These deficiencies were observed during the recertification and abbreviated surveys conducted from 4/22/2024 to 4/26/2024. Resident #2, who had a diagnosis including a fracture of the right femur and required assistance with personal care, was observed on multiple occasions with significant facial hair. Despite being cognitively intact and able to make their needs known, the resident reported that staff did not shave them or offer to shave them. Interviews with staff revealed that personal hygiene tasks, including shaving, were not consistently performed, and there was a lack of communication regarding the resident's refusal of care. Resident #12, who had diagnoses including dementia and rheumatoid arthritis, was observed with long fingernails and brown debris underneath. The resident's care plan indicated that nail care should be part of the bathing/showering task, but documentation showed incomplete records of personal hygiene being provided. Interviews with staff confirmed that nail care was not consistently performed, and the resident expressed a preference for shorter nails. Similarly, Resident #35, who had diagnoses including dementia and age-related macular degeneration, was observed with a dark substance under their fingernails, likely fecal matter. Despite documentation indicating that personal hygiene tasks were completed, interviews with staff revealed that hand hygiene before meals was rarely done, posing a risk of ingesting contaminated substances.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Hartford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Katherine Luther Residential Hlth Care & Rehab | 1.5 mi | ★★★★★ | 0 | 0 |
| Utica Rehabilitation & Nursing Center | 3.5 mi | ★★★★★ | 9 | 0 |
| Mvhs Rehabilitation And Nursing Center | 3.8 mi | ★★★★★ | 0 | 0 |
| The Grand Rehabilitation And Nursing At Utica | 4.5 mi | ★★★★★ | 0 | 0 |
| The Pines At Utica Center For Nursing And Rehab | 4.5 mi | ★★★★★ | 1 | 0 |
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