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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Schuyler Hospital Inc And Long Term Care Unit during CMS and state inspections, most recent first.
Failure to Timely Report Alleged Resident Abuse: Staff did not promptly report an alleged resident-to-resident abuse incident to the DOH after a resident reported that another resident grabbed the victim by the neck. The involved residents both had dementia and behavioral issues, and staff statements showed the allegation was known to CNAs and LPNs soon after it occurred, but administration was not notified right away because staff questioned the witness's reliability. The allegation was later reported to the DOH outside the required timeframe.
Failure to promptly investigate alleged resident-to-resident abuse and protect residents during the investigation: Staff learned that one resident allegedly placed both hands around another resident's neck, but the documented investigation did not begin until days later. The record showed the residents had dementia and behavioral histories, yet there was no nursing assessment, incident report, or other investigative documentation immediately after the event, and the investigation lacked signed statements from the involved LPNs. The DON stated the investigation was incomplete.
The facility failed to implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property by not completing nurse aide registry abuse screenings for two newly hired employees prior to their start date. The Human Resources Generalist indicated that the Onboarding Specialist misunderstood the screening requirements.
The facility failed to ensure that residents were offered, provided, or educated about influenza and pneumococcal immunizations, as evidenced by the lack of documentation for several residents. Interviews with staff confirmed the absence of verification in the electronic health records.
The facility failed to ensure privacy for two residents during insulin injections, administering the injections in public areas such as the dining room and hallway/common area. Staff interviews confirmed that injections should be given in private areas to maintain dignity.
The facility failed to implement a care plan for a resident with contractures, as the resident was observed multiple times without a required hand roll in their left hand. Despite physician orders and therapy recommendations, staff did not consistently apply the hand roll, leading to a deficiency.
The facility failed to ensure proper insulin administration for a resident with diabetes, dementia, and gastritis. Nurses did not clarify a contradictory physician order to give insulin before meals but withhold it if the resident did not eat. Insulin was administered 44 times over 15 days despite the resident refusing solid food, consuming only Ensure and juice. Staff were unaware of the complete instructions due to incomplete information in the electronic Medication Administration Record.
A resident with severe cognitive impairment and dependence on staff for oral hygiene was observed with poor oral hygiene, despite documentation indicating that care had been completed. Staff interviews and observations revealed that oral care was not consistently performed, leading to falsified records. The resident's care plan and physician's orders specified oral care twice daily, but this was not followed.
The facility failed to ensure that nurse staffing information was posted daily and included the required details such as the total number and actual hours worked by nursing staff and the current resident census. Observations and interviews revealed that the postings were outdated and lacked necessary information, and there was no clear process for updating the postings during the day.
Failure to Timely Report Alleged Resident Abuse
Penalty
Summary
The facility failed to ensure that an alleged resident abuse incident was reported to the New York State Department of Health within the required timeframe for two residents involved in a resident-to-resident altercation. On 06/07/2026, Resident #108 alleged that Resident #15 placed both hands around Resident #111's neck. Facility staff became aware of the allegation on 06/07/2026 when CNA #2 and CNA #6 notified LPN #1 and LPN #2, and Resident #111 was assessed. However, the allegation was not reported to facility administration until 06/09/2026 and was not reported to the Department of Health until 06/09/2026 at 4:25 PM. Resident #15 had diagnoses including dementia, anxiety, and depression, and the MDS dated 05/07/2026 showed severely impaired cognition with behavioral symptoms such as pacing and screaming. The care plan last revised 06/15/2026 identified a history of resident-to-resident altercations, limited insight and judgment, physical aggression, and impulsive behaviors. Resident #111 had diagnoses including dementia, muscle weakness, and depression, and the MDS showed severely impaired cognition with physical and verbal behavioral symptoms directed toward others, including grabbing and screaming. The care plan last revised 06/06/2026 identified behaviors related to dementia, including physical aggression with others, and noted the resident was at risk for becoming a victim in resident-to-resident altercations. Witness and staff statements documented that Resident #108 observed Resident #15 lunge toward Resident #111 and appear to place a hand around Resident #111's throat while Resident #111 screamed for help. RN #3 documented that CNAs reported concerns on the evening of 06/08/2026 about an incident on 06/07/2026 in which Resident #15 grabbed Resident #111 by the neck, and that no nursing note, behavior note, or incident documentation was found in the electronic record. RN Manager #1 documented being informed at approximately 3:30 PM on 06/09/2026, and the incident report and investigation both reflected that staff first became aware of the allegation on 06/07/2026, yet the report to the Department of Health was not made until 06/09/2026. Interviews with RN Manager #1, LPN #1, and the DON confirmed that staff did not report the allegation immediately because they did not believe the witness, even though they stated administration should have been notified right away.
Failure to promptly investigate alleged resident-to-resident abuse and protect residents during the investigation
Penalty
Summary
The facility failed to ensure an alleged resident-to-resident abuse incident was thoroughly investigated and that the residents were protected while the investigation was in progress for two residents. On 06/07/2026, staff became aware of an allegation that Resident #15 placed both hands around Resident #111's neck. Although LPN #1 and LPN #2 were notified immediately after the alleged incident, the facility did not begin a documented investigation until RN Manager #1 became aware of the allegation on 06/09/2026 at about 3:30 PM. The facility Abuse Policy required investigations to begin immediately upon receipt of a concern and required resident protection while the investigation was ongoing. Resident #15 had diagnoses including dementia, anxiety, and depression, and the MDS dated 05/07/2026 showed severely impaired cognition. The care plan identified a history of resident-to-resident altercations, limited insight and judgment, physical aggression, and impulsive behaviors. Resident #111 had diagnoses including dementia, muscle weakness, and depression, and the care plan identified behaviors related to dementia, including physical aggression with others and risk for becoming a victim of resident-to-resident altercations. The record contained no nursing assessment, behavior note, incident report, physician notification, family notification, or other investigative documentation on 06/07/2026 or 06/08/2026. RN #3 documented that CNAs reported concerns on the evening of 06/08/2026 about an incident involving the two residents, and that LPN #1 was aware of the incident, but no written documentation had been completed before RN Manager #1 was notified. The facility investigation dated 06/09/2026 did not include signed statements from LPN #1 or LPN #2, and the state investigative report listed the incident date as 06/09/2026 rather than 06/07/2026, despite conflicting documentation about how the event was discovered. The DON stated the investigation was incomplete because statements were not obtained from all staff involved.
Failure to Implement Abuse Prevention Screening Procedures
Penalty
Summary
The facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, a nurse aide registry abuse screening was not completed for two newly hired employees prior to starting work. A Resident Assistant was hired, and the nurse aide registry screen for prior abuse findings was not submitted until over a month later. Similarly, a Dietary Aide was hired, and the nurse aide registry screen for prior abuse findings was also delayed. During an interview, the Human Resources Generalist explained that the Onboarding Specialist mistakenly believed that only Certified Nursing Assistants needed to be run through the nurse aide registry.
Failure to Document and Offer Vaccinations
Penalty
Summary
The facility did not ensure that influenza and pneumococcal immunizations were offered, provided, or that education was given to residents or their representatives. Specifically, there was no documented evidence that Resident #64, who had chronic obstructive pulmonary disease, heart failure, and dementia, was offered, provided, declined, or educated about the pneumococcal vaccine. Similarly, Residents #15, #23, #48, and #59 had no documented evidence of being offered, receiving, declining, or being educated about the influenza vaccine for the current flu season. Resident #15, with dementia, anxiety, and depression, had no record of receiving the influenza vaccine for this year's flu season. Resident #59, with chronic obstructive pulmonary disease, diabetes, and kidney disease, had no documentation regarding the influenza vaccine for this year, despite having received it in 2022. Resident #23, with spinal stenosis, atrial fibrillation, and depression, had no documented evidence of education or declination regarding the influenza vaccine. Interviews with the Infection Control Nurse and the Director of Nursing revealed that there was no verification in the electronic health records that the residents were offered or declined the vaccines. The facility's policies stated that pneumococcal vaccine status should be verified on admission and offered if not current, and that the influenza vaccine should be offered annually during the flu season. However, these policies were not followed, leading to the deficiencies noted in the survey.
Lack of Privacy During Insulin Injections
Penalty
Summary
The facility did not ensure that residents were treated with respect and dignity during medication administration. Specifically, staff failed to provide privacy for two residents during the administration of insulin injections. Resident #59, who has diagnoses including diabetes, obesity, and lymphedema, was observed receiving an insulin injection in the dining room in the presence of other residents. The resident lifted their shirt, exposing their abdomen, and the injection was administered by a registered nurse. Similarly, Resident #5, who has diagnoses including diabetes, dementia, and gastritis, was observed receiving an insulin injection in the hallway/common area, also in the presence of other residents. The resident was wheeled out of the dining room for the injection, but privacy was not ensured. Interviews with staff revealed that the general rule is to administer medications, including injections, in residents' rooms to ensure privacy. However, it was noted that injections were occasionally given in public areas such as the dining room or hallway/common area. The Director of Nursing and Registered Nurse Manager confirmed that injections should be administered behind a door or curtain to provide dignity and privacy, and that public areas were not appropriate for such procedures. The failure to provide privacy during these medical procedures compromised the residents' dignity and quality of life.
Failure to Implement Care Plan for Resident with Contractures
Penalty
Summary
The facility did not ensure that Resident #27's person-centered care plan was implemented to meet the resident's goals and outcomes. Resident #27, who had diagnoses including Alzheimer's disease, anxiety, and contractures, was observed multiple times without a hand roll in their left hand, despite physician orders and therapy recommendations. The resident's care plan and Kardex indicated the need for a hand roll to be placed in the left hand at all times, except during meals and care. However, observations on three separate occasions revealed that the hand roll was not in place, and interviews with staff confirmed the oversight. The Minimum Data Set Resident Assessment indicated that Resident #27 had severely impaired cognition and was totally dependent on staff for care. The Occupational Therapist confirmed that the hand roll was recommended during an assessment, and Certified Nursing Assistants acknowledged the requirement but failed to implement it consistently. The Nurse Manager admitted that staff should follow the care plan but was unaware of why the hand rolls were not being used. This failure to implement the care plan as prescribed led to the deficiency noted in the report.
Failure to Clarify Insulin Administration Orders
Penalty
Summary
The facility did not ensure that the services and care provided met professional standards of quality for Resident #5, who had diagnoses including diabetes, dementia, and gastritis. Specifically, several nurses failed to clarify a contradictory physician order regarding insulin administration. The order stated to administer insulin before meals but also included instructions to withhold insulin if the resident did not eat. Despite Resident #5's poor food intake, insulin was administered 44 times over a 15-day period when the resident refused all solid food, consuming only Ensure and juice. This discrepancy was observed during multiple instances where insulin was given before meals, and the resident did not consume solid food afterward. The nurses were unaware of the complete instructions due to the electronic Medication Administration Record not displaying the additional instructions to withhold insulin if the resident did not eat. Interviews with the nursing staff and management revealed a lack of awareness and understanding of the physician's order. Licensed Practical Nurse #1 admitted to not knowing about the instruction to withhold insulin if the resident did not eat and stated that the electronic record did not show this information. Registered Nurse Manager #3 and the Director of Nursing acknowledged the contradictory nature of the order and the need for clarification, which had not been sought. The Nurse Practitioner confirmed that the insulin sliding scale order should have been clarified with the medical provider. This failure to clarify the physician's order and ensure proper insulin administration led to the deficiency noted in the survey report.
Failure to Provide Necessary Oral Hygiene Services
Penalty
Summary
The facility did not ensure that a resident who is unable to carry out Activities of Daily Living received the necessary services to maintain good oral hygiene. Specifically, a resident with severe cognitive impairment and dependence on staff for oral hygiene was observed on multiple occasions with poor oral hygiene, including large amounts of thick yellow plaque on their lower teeth. Despite documentation indicating that oral care had been completed, interviews with staff and the resident revealed that oral hygiene had not been performed as required. The resident's care plan and physician's orders specified oral care twice daily, but the Kardex used by Certified Nursing Assistants did not include instructions on the frequency or timing of oral care. Observations and interviews with staff indicated that oral care was supposed to be part of morning and bedtime routines, but it was not consistently performed. Certified Nursing Assistants and nurses were found to be signing off on oral care without verifying its completion, leading to falsified records. The resident's representative also noted that oral care was often not completed during their visits. The Director of Nursing confirmed that oral care should be completed as ordered and at a minimum daily if the resident allows. The deficiency was identified during a Recertification Survey, highlighting a failure to provide necessary services for maintaining good oral hygiene for a dependent resident.
Failure to Post Accurate Nurse Staffing Information Daily
Penalty
Summary
The facility did not ensure that nurse staffing information was posted daily and included the required information. Specifically, the nurse staffing information did not consistently include the total number and actual hours worked by licensed and unlicensed nursing staff who were directly responsible for resident care, the current resident census, and was not posted at the beginning of each shift to include any staffing changes as per the regulations. Observations on multiple dates revealed that the posted nurse staffing information was outdated and lacked the current resident census. Additionally, the nurse staffing information form from 2/26/24 to 3/26/24 showed multiple days missing the total number of actual hours worked by each discipline or the resident census. Interviews with facility staff, including an administrative assistant, a nursing coordinator, and the Director of Nursing, indicated that the night supervisor was responsible for posting the nurse staffing information. However, there was no clear process for updating the postings during the day when staffing changes occurred. The staff also demonstrated a lack of awareness regarding the requirement to include the current resident census in the postings. The Director of Nursing acknowledged that the postings should be updated during the day to reflect any staffing changes.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Montour Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Nursing Home & Health Related Facility Inc | 11.2 mi | ★★★★★ | 0 | 0 |
| Elcor Nursing And Rehabilitation Center | 13 mi | ★★★★★ | 6 | 0 |
| Corning Center For Rehabilitation And Healthcare | 17.3 mi | ★★★★★ | 0 | 0 |
| St. Joseph's Hospital - Skilled Nursing Facility | 18.3 mi | ★★★★★ | 3 | 0 |
| Chemung County Health Center - Nursing Facility | 18.3 mi | ★★★★★ | 0 | 0 |
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