Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Camillus Residential Health Care Facility during CMS and state inspections, most recent first.
The deficiency centers on prolonged call bell response times that conflicted with facility policy and residents’ rights to dignity and timely assistance. All residents in a group meeting reported long waits for call bell responses, and call bell system records showed multiple instances of lights remaining on for 36–70 minutes. In one detailed case, a resident needing toileting assistance had their call bell active for an extended period while staff entered only briefly to turn off the light and defer the request to others, requiring the resident to reactivate the call bell multiple times before being assisted. Staff, including CNAs, a medical secretary, an LPN manager, and an RN coordinator, acknowledged that everyone was responsible for answering call bells, that expected response times were 5–15 minutes, and that waits over 30 minutes were excessive, yet such extended waits still occurred.
Surveyors found that the facility did not follow its own food safety and cleaning policies in the main kitchen, including failing to label and date multiple food items, retaining expired sour cream and milk in a walk-in cooler, and allowing debris and residue to accumulate in several coolers and ovens. The dish machine was observed in use while not reaching required sanitizing temperatures, and the daily temperature check had not been recorded as usual. Kitchen leadership acknowledged that dishes should not be used if the machine is not sanitizing properly, and a nurse reported previously finding and discarding spoiled milk in a unit refrigerator.
Surveyors found multiple medication carts with unlabeled or expired meds, including insulin pens, inhalers, nasal sprays, eye drops, and vitamin C. An LPN and other staff stated these items should have been dated when opened and discarded when expired, but several were left in the carts without open or expiration dates, and supplies were also stored on the floor in a med room.
Infection Control Failures With Mask Compliance and Droplet Precautions: Two staff who declined the flu vaccine were observed wearing masks below the nose in resident areas, including near residents in a dining room and at the nurse’s station. In addition, staff entered rooms of residents on droplet precautions for influenza A and/or COVID-19 without required eye protection, and one LPN/Assistant Unit Manager provided bedside care without gown, gloves, or a face shield. The isolation caddy for one resident also lacked eye protection.
Surveyors found that the facility did not follow its self-medication policy when two residents kept medications and supplements at their bedside without required assessments or provider orders. One resident with respiratory failure and a fungal lung infection had a prescribed ipratropium nasal spray on the overbed table, despite no documented self-administration order or assessment, while nursing staff continued to administer the medication on a scheduled basis. Another resident with heart disease, syncope, moderate cognitive impairment, and upper extremity impairment had elderberry supplements at the bedside and reported taking them daily, even though prior elderberry and other supplements had been discontinued due to polypharmacy and there were no current orders or care plan for self-administration. Staff, including an LPN, the unit manager, and the DON, acknowledged that medications should not be kept at the bedside without an assessment and provider order.
A resident with severe cognitive impairment and dependence on staff for most ADLs did not receive required hygiene and grooming care as outlined in facility policies and the care plan. The resident, who required assistance with oral care and was dependent for personal hygiene, was observed on multiple occasions with long, jagged fingernails containing brown debris, foul breath, and unshaven facial hair, and reported never refusing showers and wanting full grooming care. A CNA stated that showers and bed baths should include washing, hair care, oral care, and nail care, but acknowledged that on the resident’s scheduled shower day only a bed bath was given due to limited staffing and the need for a mechanical lift, and that hair washing, oral care, nail care, and shaving were not performed. The ADON confirmed that showers were expected to be completed as scheduled and that sometimes care, including showers, was not completed because of short staffing.
A resident with brain injury, dementia, and impaired mobility had a crisscross lap belt used as a restraint in a wheelchair for safety because of impulsivity and unsafe standing attempts. Records showed the device was treated as a restraint, but there was no documented evidence it was the least restrictive option, medically warranted for ongoing use, or periodically re-evaluated for reduction or removal. Staff interviews confirmed the belt had been used for years, prevented the resident from standing, and no alternative devices or restraint reduction trials had been attempted.
Two residents had comprehensive care plans that did not include key medication-related needs. One resident with a history of blood clots was receiving Eliquis, but the care plan did not address anticoagulant use or bleeding monitoring. Another resident with diabetes and atrial fibrillation was receiving insulin and heparin, but the care plan did not include insulin management, blood sugar monitoring, or anticoagulant-related monitoring. Staff interviews confirmed the omissions.
A resident receiving hemodialysis had no documented ongoing pre- and post-dialysis assessments or consistent access-site checks, and the facility did not reliably review or complete the dialysis communication book or contact the dialysis center when needed. The resident also reported that lunch was often not sent on dialysis days, and staff observations showed the meal and communication binder were sometimes not prepared until the resident asked for them.
Failure to provide planned double portions: A resident with food insecurity, protein calorie malnutrition, and depression was supposed to receive double portions at meals, but staff and survey observations showed the resident often did not get the ordered amounts. The resident reported ongoing hunger after meals, and the meal ticket specified larger portions than what was actually served.
Prolonged Call Bell Response Times Undermining Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to dignity and timely response to needs, particularly regarding call bell response times. Facility policies stated that residents had a right to a dignified existence and that staff were expected to respond to call bells within 10–15 minutes, with response to resident needs taking priority over routine tasks and being the responsibility of all staff regardless of role or assignment. During a confidential group meeting, all 13 of 13 residents present reported experiencing long call bell response times. Review of the call bell monitor at the nurses’ station showed multiple instances of prolonged unanswered call lights, including one resident’s call bell on for 70 minutes, another resident’s call bell on for 39 minutes, another for 36 minutes, and another for 40 minutes. Further observations and interviews detailed a specific incident involving one resident whose call bell remained on for extended periods while their toileting needs were not promptly met. On one occasion, the call bell monitor showed this resident’s call bell active for 70 minutes before a CNA briefly entered, turned off the call bell, and left, stating the resident wanted their table moved and to get up and that they would inform the assigned aide. The resident later reported believing their light had been on for about an hour and that they needed to use the bathroom. The call bell was reactivated, and a medical secretary subsequently entered, turned off the call bell, and exited without meeting the resident’s stated need, after which the call bell was again turned on until staff eventually assisted the resident to the bathroom. Staff interviews confirmed that all staff were responsible for answering call bells, that expected response times were 5–15 minutes, and that wait times of 30 minutes or more were considered excessive. A clinical coordinator acknowledged having seen long wait times on the call bell monitor in the past and agreed that 40- and 70-minute waits were excessive and that no one should wait that long.
Food Storage, Sanitation, and Equipment Failures in Main Kitchen
Penalty
Summary
Surveyors identified that the facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards in the main kitchen. Policy required that food be labeled, dated, rotated using first-in/first-out, and discarded when outdated or showing evidence of spoilage, and that refrigerators and ovens be cleaned per daily and weekly schedules. During observations, surveyors found multiple unlabeled food items, including a bag of meat, cheese slices, a white bag of food, and a meat salad in the upstairs walk-in cooler, preparation refrigerator, and salad refrigerator. They also found expired food in the upstairs walk-in cooler, including two large containers of sour cream past the labeled expiration date and two cases of milk beyond their expiration date. The sandwich, preparation, and salad coolers contained accumulated debris and residue, and the ovens had dried-on, burnt food spillage on the bottom despite procedures requiring immediate cleanup of spills and daily or weekly cleaning. Surveyors further observed that the dish machine was not functioning properly while staff were actively washing breakfast dishes. The dish machine temperature dial did not move above 120°F during the wash and sanitation cycles, and the temperature for that day had not been checked or recorded at the time of observation, contrary to staff statements that temperatures were normally taken and recorded daily after the machine warmed up. The Executive Chef and Food Service Director both acknowledged that dishes should not be used if the dish machine was not cleaning or sanitizing at the required temperature. The Food Service Team Lead reported they usually recorded the dish machine temperature after warm-up but had forgotten that morning. Additionally, an LPN reported having previously found outdated and spoiled milk in a unit refrigerator and discarding it without serving it. These observations and interviews demonstrated noncompliance with the facility’s own food safety, labeling, rotation, and cleaning policies and procedures in the main kitchen and related food service areas.
Unlabeled and Expired Medications Found in Multiple Medication Carts
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles in multiple medication carts and one medication room. Surveyors found unlabeled insulin pens, inhalers, nasal sprays, and eye drops in the Unit 2 [NAME], Unit 2 East, Unit C, and Unit D medication carts, along with expired medications left in the carts. In the Unit 2 medication room, supplies were stored directly on the floor under the sink. During observations, the Unit 2 [NAME] cart contained two lispro insulin pens and one Lantus insulin pen without open or expiration dates, and a vitamin C container that had expired in 12/2024. The Unit 2 East cart contained a Lantus insulin pen without an open or expiration date and a budesonide inhaler opened on 11/18/2025. The Unit D cart contained eye drops that expired in 01/2022, a Lantus insulin pen and a lispro insulin pen without open or expiration dates, and a Trelegy Ellipta inhaler without an open or expiration date. The Unit C cart contained two lispro insulin pens labeled with open or expiration dates, but also had four nasal sprays without open or expiration dates, atropine 1% eye drops opened on 09/12/2025 and expired 10/01/2025, and two Trelegy Ellipta inhalers plus one Incruse Ellipta inhaler without open or expiration dates. Staff interviews stated insulin pens, nasal sprays, and inhalers were supposed to be dated when opened and discarded after the applicable time period, but several staff members said the items were not labeled, were overlooked, or were left in the carts despite being expired.
Infection Control Failures With Mask Compliance and Droplet Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for staff influenza vaccination compliance and for residents on droplet precautions. Two staff members, a Certified Nurse Aide and an Environmental Services Worker, declined the influenza vaccine and were required to wear masks while working, but both were observed with their masks below their noses in resident areas on multiple occasions. The CNA was also observed with the mask below the nose while talking to a resident at the nurse’s station and while walking through the dining room where 11 residents were seated. The Infection Preventionist stated the CNA had been observed not wearing the mask appropriately and needed reminders to wear it correctly. Five residents were on droplet precautions after testing positive for influenza A and/or COVID-19. Resident #66 tested positive for influenza A and COVID-19, and an LPN entered the room without eye protection. Resident #87 tested positive for COVID-19, and the isolation caddy outside the room contained gowns and masks but no eye protection. Resident #195 tested positive for influenza A and COVID-19, and an LPN/Assistant Unit Manager stood at the bedside talking with the resident without a gown, gloves, or face shield, stating this was an oversight. Resident #244 tested positive for influenza A, and a CNA entered the room without eye protection. Resident #268 tested positive for influenza A, and both an LPN and a CNA entered the room without eye protection. The facility’s droplet precaution signage stated staff must clean hands when entering and leaving the room and use gown, glove, and eye cover if contact with secretions is likely. During interviews, the LPN and CNA stated they did not wear eye protection when entering rooms on droplet precautions, and the CNA stated they did not think eye protection was needed because they did not expect exposure to secretions. The Infection Preventionist stated residents who tested positive or were suspected of having influenza or COVID-19 were placed on droplet precautions and staff were expected to wear gown, gloves, and eye protection during close contact due to the risk of secretions from droplets.
Failure to Assess and Authorize Resident Self-Administration of Medications at Bedside
Penalty
Summary
The facility failed to ensure the interdisciplinary team determined residents' ability to safely self-administer medications, as required by policy, before medications or supplements were kept at the bedside. Facility policy on self-medication required identification of appropriate residents, a provider order, completion of a self-medication administration record, and use of a pharmacy-filled pill holder stored in a locked cart or locked resident drawer. For one resident with acute and chronic respiratory failure and aspergillosis, who had intact cognition and required set-up to moderate assistance with activities of daily living, surveyors observed a prescribed ipratropium bromide nasal spray on the overbed table on multiple occasions without licensed staff present. There was no documented provider order for self-medication administration and no self-medication assessment, even though the medication administration record showed the nasal spray was ordered and being administered by nursing staff at scheduled times. An LPN and the RN Unit Manager both confirmed that residents should not have medications at the bedside without an assessment and provider order, and acknowledged that this resident did not have such an order and that the nasal spray should have been kept in the locked medication cart. For another resident with heart disease, syncope, collapse, moderate cognitive impairment, and one-sided upper extremity mobility impairment, surveyors observed elderberry supplements on the bedside table on two separate days. The resident’s prior order for an elderberry zinc/vitamin C/immune lozenge had been discontinued months earlier, and a nurse practitioner note documented discontinuation of multiple vitamins and elderberry tablets due to polypharmacy. There was no current provider order for elderberry supplements, no order for self-medication administration, and no comprehensive care plan addressing the ability to self-administer medications. An LPN stated the resident was not taking any supplements and had no self-administration orders, confirmed the presence of elderberry supplements at the bedside, and stated the resident should not possess medications that were not ordered. The resident reported taking the elderberry supplements daily since admission, brought in by a family member. The DON stated residents should not have medications at the bedside without a provider order and proof they could take them safely, and confirmed that both the elderberry supplements and nasal spray were medications that should not have been at the bedside without an order and assessment.
Failure to Provide Required ADL, Hygiene, and Grooming Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs)—including bathing, grooming, oral care, and fingernail care—to a resident who was unable to perform these tasks independently. Facility policies required that residents who could not carry out ADLs receive services to maintain good grooming, personal and oral hygiene, and fingernail care. The resident had severe cognitive impairment, did not reject care, and was documented as requiring partial/moderate assistance for oral care and being dependent for most ADLs. The care plan and resident profile specified that the resident was dependent for personal hygiene, required supervision with oral hygiene and bathing/showers, and was scheduled for a weekly shower on a specific weekday during the day shift. Surveyors observed the resident on multiple occasions with jagged fingernails containing brown debris, foul breath, and unshaven facial hair. The resident reported not knowing their shower day, never refusing showers, not remembering the last shower, and wanting their hair washed and combed, nails cleaned and cut, teeth brushed, and to be shaved, stating they were always clean shaven. CNA interview revealed that showers were to include washing the resident and hair, brushing teeth, and clipping nails, and that on non-shower days bed baths should include body washing, hair combing, tooth brushing, and nail care. The CNA stated the resident was scheduled for a shower but did not receive it because the resident required a mechanical lift and staffing was limited, so only a bed bath was provided without shampooing hair, oral care, nail care, or shaving. The ADON acknowledged that showers were expected to be completed by the scheduled shift and that at times care, including showers, was not completed due to short staffing.
Failure to Reassess Least Restrictive Use of a Crisscross Lap Belt
Penalty
Summary
The facility failed to ensure that when a physical restraint was used, the least restrictive alternative was selected and the need for the restraint was re-evaluated over time for one resident. Resident #13 had diagnoses including brain injury, dementia, and difficulty walking, and the resident used a manual wheelchair with severely impaired cognition. The resident had a crisscross lap belt attached to the back of the wheelchair, with physician orders directing that it not be released during meals and be released every 2 to 3 hours and as needed for care. Record review showed the resident’s care plan identified the crisscross belt as a physical restraint related to long-standing traumatic brain injury and included monitoring, consent, positioning, and release every 2 to 3 hours. A restraint evaluation form completed by the RN Unit Manager documented that the resident could not release the device on request, that it impaired the resident’s pre-existing functional ability, and that it was a restraint. However, there was no documented evidence that the crisscross belt was determined to be the least restrictive device, that medical symptoms warranted its ongoing use, or that a plan to reduce or eliminate the restraint had been attempted. Staff interviews indicated the device had been used for safety because the resident was impulsive and attempted to stand without help. Nursing staff stated the resident had used the crisscross belt for years, that it prevented standing, and that they were unaware of any other devices tried. The RN Unit Manager stated there had been no attempts to trial different devices or reassess for reduction, and the DON stated the restraint should be reviewed quarterly, annually, and with significant status changes, including a restraint holiday, but was unaware that no reduction attempts had been made. The physician also stated the least restrictive device should be used and reduction should be assessed if possible.
Care Plans Omitted Anticoagulant and Insulin Needs
Penalty
Summary
The facility failed to ensure that comprehensive person-centered care plans were developed and implemented for two residents to include services needed to maintain their highest practicable physical well-being. For one resident with diagnoses including a history of blood clots, embolism, and long-term anticoagulant use, the 12/29/2025 MDS documented moderate cognitive impairment and anticoagulant use, and the physician order dated 12/22/2025 ordered Eliquis 5 mg by mouth twice daily for a history of DVT. However, there was no documented evidence that the resident’s care plan included the anticoagulant or monitoring for symptoms of anticoagulant use. During interviews, an LPN stated they were unsure whether the anticoagulant should be on the care plan, and the RN manager stated its absence was an oversight and that it was important for staff awareness and monitoring for bleeding, especially given the resident’s history of falls and recent hematuria. For another resident with diagnoses including diabetes and atrial fibrillation, the 12/18/2025 MDS documented cognitive intactness and daily insulin and anticoagulant use. Physician orders included heparin 5,000 units subcutaneously twice daily for DVT prophylaxis, insulin aspart before meals per sliding scale with notification parameters for abnormal blood sugars, and Lantus 30 units at bedtime. There was no documented evidence that the care plan included insulin use and monitoring for hyperglycemia or hypoglycemia, or anticoagulant use and monitoring for side effects. During interviews, a CNA stated care plans should include what to monitor for when a resident is diabetic and on insulin, and the LPN and RN manager stated the resident’s diabetes, insulin use, and anticoagulant use should have been included so staff would know to monitor for blood sugar changes and bleeding or bruising.
Dialysis communication, access-site monitoring, and meal provision were inconsistent
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident with end-stage renal disease who received hemodialysis three times weekly at a community dialysis center. The resident’s care plan documented dialysis and restrictions on the arm with the graft, but there was no documented evidence of the dialysis access site location, a plan for monitoring the access site, or completion of pre- and post-dialysis assessments. The physician order required the communication book to accompany the resident to dialysis and for nursing to review it on return, contact the dialysis center if needed, and monitor the access site for bleeding, edema, or other complications, but there was no documented evidence that these steps were consistently completed. The dialysis communication book contained treatment summaries from the dialysis center, including pre- and post-dialysis weights, blood pressures, medications, and labs on several treatment days, but there was no documented evidence that facility staff reviewed the information after the resident returned. There were no communication summaries for one month, and multiple entries in the communication book were incomplete, unsigned, or undated. There was also no documentation that the facility contacted the dialysis center on several treatment days when no feedback was recorded, and no documentation that the resident or access site was assessed after return from dialysis on multiple occasions. During observations and interviews, the resident stated staff rarely checked the access site after dialysis and sometimes took blood pressure but not often. The resident also stated they were often not sent to dialysis with a lunch and became hungry during treatment. On one observed dialysis departure, the resident asked staff for lunch and the lunch was found in the resident’s room and brought to them; the communication book was also retrieved and placed on the wheelchair after the resident requested it. The dialysis center nurse stated the resident rarely arrived with the communication form completed and therefore the center had no knowledge of medication changes or changes in medical status.
Failure to Provide Planned Double Portions
Penalty
Summary
The facility failed to ensure accommodation of resident food preferences for one resident who was planned to receive double portions at meals. The resident had diagnoses including food insecurity, protein calorie malnutrition, and depression, and the hospital discharge summary documented treatment for starvation ketoacidosis. The comprehensive care plan initiated after admission documented that the resident was to receive double portions at meals, and the dietitian notes documented double portions for nutrition supplementation and increased calorie and protein needs to heal wounds. During the survey, the resident stated they had requested double portions when admitted but often did not receive them and remained hungry after meals, relying on snacks on the unit. An observation showed the resident received 6 ounces of beef stew and 1/2 cup of mashed potatoes, while the meal ticket documented 12 ounces of beef stew and 1 cup of mashed potatoes. Staff interviews confirmed the resident often asked for extra food, that this was an ongoing issue, and that the resident was supposed to receive double entree breakfast, lunch, and dinner, double starch at lunch and dinner, and double sides at breakfast.
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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 Syracuse
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Upstate University Hosp At Community General T C U | 2.7 mi | ★★★★★ | 0 | 0 |
| Van Duyn Center For Rehabilitation And Nursing | 2.9 mi | — | 54 | 6 |
| Central Park Rehabilitation And Nursing Center | 3 mi | ★★★★★ | 0 | 0 |
| Bishop Rehabilitation And Nursing Center | 3.9 mi | ★★★★★ | 6 | 0 |
| Loretto Health And Rehabilitation Center | 4.2 mi | ★★★★★ | 20 | 0 |
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