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 The Commons On St Anthony, A S N F & Short T R C during CMS and state inspections, most recent first.
Two residents with intact cognition did not receive personal fund statements within the required timeframe, as per facility policy. One resident had not received a statement since admission, and another's family had to request balances quarterly. The facility's process for distributing statements was inconsistent, with statements being sent to a social worker instead of directly to residents or families, leading to a failure in providing timely financial information.
A facility failed to implement a comprehensive care plan for a resident with dementia and muscle weakness, who was observed without necessary footrests and lateral supports in their scoot chair. Despite care plan interventions requiring repositioning and support, staff did not consistently adhere to these measures, leading to the resident being improperly positioned. Interviews revealed a lack of documentation and consistent practice in repositioning the resident, contributing to the deficiency.
A resident requiring hemodialysis did not receive proper assessments and monitoring before and after treatments, and there was inconsistent communication between the dialysis center and the facility. The resident, who had end-stage renal disease and diabetes, often did not complete treatments due to discomfort from a mechanical lift pad, and staff failed to notify medical personnel. Additionally, the resident did not receive a necessary bagged lunch to manage their diabetes, and documentation errors were noted regarding the resident's vascular access.
The facility did not post daily nurse staffing information, including the resident census and staff hours, in a location accessible to residents and visitors. The information was placed on a door down a hallway, not easily accessible, and lacked the daily census on one occasion. Staff were unaware of the requirement for accessibility.
A resident with epilepsy missed 24 out of 26 doses of levetiracetam, a seizure medication, due to inadequate documentation and communication at the LTC facility. The medication was not administered on dialysis days as ordered, and staff failed to notify medical personnel of the missed doses.
The facility failed to maintain an effective infection prevention and control program, with deficiencies observed in PPE use and urinary drainage bag management. A staff member did not adhere to PPE protocols while cleaning a COVID-19 positive resident's room, risking virus spread. Additionally, two residents' urinary drainage bags were improperly stored, with one bag lacking a protective cap and another resting on the floor, contrary to infection control guidelines.
A facility failed to maintain resident dignity and privacy by posting personal care information visibly in a resident's room and using misleading 'out of order' signs on elevators to deter cognitively impaired residents. The resident's care instructions were improperly displayed, and the elevator signs confused visitors and residents, contradicting the facility's dignity policy.
A facility restricted a resident's family member from visiting late at night based on the healthcare proxy's wishes, despite the resident's ability to express needs and no documented concerns from the resident. The facility's visitation policy allowed 24/7 access, but inconsistencies in enforcement led to the restriction, even though the resident was at the end of life and valued family visits.
Two residents in an LTC facility did not receive appropriate care and follow-up. One resident with bilateral above-the-knee amputations did not have timely follow-up on a prosthetics referral, while another resident experienced an emotionally distressing event that was not addressed promptly. The facility's failure to document and act on these issues highlights deficiencies in their care processes.
A resident with a history of UTIs and antibiotic resistance was observed with a leg bag improperly positioned, contrary to facility policy, leading to a deficiency in preventing UTIs. Staff interviews revealed non-compliance with catheter care protocols, contributing to the resident's recurrent infections and hospitalizations.
A resident with heart disease and hypertension did not receive the RSV vaccine timely after it was ordered in 2023 and 2024. The facility's policy required vaccine administration with consent, but there was no evidence of administration in 2023, and it was delayed in 2024. Staff interviews revealed a lack of communication and tracking, leading to the vaccine order falling through the cracks.
The facility did not maintain a surety bond sufficient to cover the total resident funds deposited, affecting 239 residents. The bond was for $250,000, while resident funds ranged from $286,256.24 to $309,980.04. Staff interviews revealed a lack of awareness and oversight regarding the bond coverage and account balances.
The facility failed to ensure residents' rights to receive mail were maintained, as mail was not delivered on Saturdays and some residents reported their mail was opened before delivery. Staff interviews revealed inconsistencies in the mail delivery process, with social workers responsible for distribution not working on weekends, leading to delays and privacy violations.
Failure to Provide Timely Personal Fund Statements
Penalty
Summary
The facility failed to provide two residents with personal fund statements within 30 days after the end of the quarter and upon request, as required by their policy. Resident #93, who has Parkinson's Disease and intact cognition, and Resident #198, who has Sjogren syndrome and intact cognition, were both affected. Resident #198 reported not receiving a statement since admission, approximately 8-9 months ago, and was only given an account balance upon request. Resident #93's family member also reported not receiving statements and having to ask for a balance quarterly. The facility's policy stated that resident fund statements should be delivered quarterly and be available upon request during banking hours. However, discrepancies were noted in the distribution process, with statements for Residents #93 and #198 being sent to a social worker instead of directly to the residents or their families. Financial Associate #5 and Accounting Manager #4 were involved in the process, but there was confusion about who was responsible for ensuring statements were distributed. Social Worker #16 admitted to not handing statements to the affected residents, indicating a breakdown in communication and procedure adherence.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #20, who was observed without necessary footrests and lateral supports while in their scoot chair. The resident, diagnosed with dementia, abnormal posture, and muscle weakness, was dependent on staff for activities of daily living and used a wheelchair. The care plan, revised in October 2024, included interventions such as using footrests and bilateral lateral supports in the scoot chair, which were not consistently implemented. Observations during the survey revealed multiple instances where Resident #20 was leaning forward or to the side in their scoot chair without proper support, indicating a lack of adherence to the care plan. Staff interviews confirmed that the resident was supposed to be repositioned every two hours, but this was not documented or consistently practiced. The resident's family expressed concerns about the resident's positioning, and staff acknowledged the absence of necessary supports and the failure to reposition the resident as required. The Occupational Therapist noted that the resident required total assistance with positioning and that the lateral supports were not in place during the survey. The Registered Nurse Manager admitted to seeing the resident in improper positions and not taking corrective action. The facility's failure to ensure the implementation of the care plan and proper documentation led to the deficiency identified during the survey.
Inadequate Dialysis Care and Communication for a Resident
Penalty
Summary
The facility failed to provide adequate dialysis care and services for Resident #152, who required hemodialysis treatments at a community-based dialysis center. The resident did not receive ongoing assessments of their condition and monitoring for complications before and after dialysis treatments. There was inconsistent communication and collaboration between the dialysis center and the facility, as evidenced by incomplete or missing documentation in the dialysis communication book. Additionally, the resident did not receive a bagged lunch prior to attending dialysis, which was necessary to manage their diabetes and prevent low blood sugar levels. Resident #152, who had diagnoses including end-stage renal disease, diabetes, and hemiplegia following a stroke, frequently did not complete dialysis treatments due to discomfort from a mechanical lift pad left under them in their wheelchair. Despite the resident's complaints of discomfort and the presence of a sore on their buttocks, staff did not notify medical personnel or make necessary adjustments to alleviate the discomfort. The facility's policy required that the resident's vascular access site be examined and assessed, but there were multiple instances where this was not documented, and staff incorrectly documented the presence of a permacath, which the resident did not have. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's needs and the issues affecting their dialysis treatments. The Assistant Director of Nursing/Interim Nurse Manager and other staff members were not aware of the resident's discomfort or the incomplete dialysis treatments. The facility's failure to ensure proper communication, assessment, and care for Resident #152 led to deficiencies in the provision of dialysis services, which are critical for managing the resident's health conditions.
Failure to Post Nurse Staffing Information in Accessible Location
Penalty
Summary
The facility failed to post daily nurse staffing information, including the current resident census and the total number of hours worked by licensed and unlicensed nursing staff, in a location that was readily accessible to residents and visitors. During the recertification survey conducted from 10/28/2024 to 11/1/2024, it was observed that the staffing information was posted on the nursing Supervisor/Staffing office door, which was located down a hallway off the main lobby, making it not easily accessible to visitors and residents. This issue was noted for all five days of the survey period, and on 11/1/2024, the posted information did not include the daily census. Interviews with facility staff revealed a lack of awareness regarding the requirement for the nurse staffing information to be posted in a readily accessible location. The Staffing Supervisor stated that they were responsible for overseeing the staffing department and ensuring the schedules were posted, but they were not aware that the location was not accessible to visitors and residents. The Director of Nursing also acknowledged the requirement but believed the current posting location was sufficient, as visitors and residents might pass by the area to use the bathroom or go to the bank. There was no documented facility policy on nurse staffing posting requirements, contributing to the deficiency.
Failure to Administer Seizure Medication on Dialysis Days
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of levetiracetam, a medication used to treat seizures. The resident, who had a history of epilepsy and required dialysis, was prescribed an additional dose of levetiracetam to be administered on dialysis days. However, the resident missed 24 out of 26 doses of this medication over a two-month period. The facility's policy on medication administration did not adequately address the documentation required when a resident was out of the building during scheduled medication times, contributing to the oversight. The Medication Administration Record indicated that the resident was frequently marked as "absent from home without medications" on dialysis days, and there was no documentation of the medication being administered after dialysis as ordered. Interviews with staff revealed a lack of communication and understanding regarding the importance of the medication and the need to notify medical personnel of missed doses. The LPN responsible for the resident did not relay information about the missed doses to the next shift, and the Assistant Director of Nursing was unaware of the missed doses until the survey. The Physician Assistant, who was responsible for the resident's care, was not informed of the missed doses and expressed surprise at the lack of administration. Despite the resident not experiencing another seizure since returning from the hospital, the failure to administer the medication as ordered was a significant oversight. The facility's failure to adjust the medication administration time to accommodate the resident's dialysis schedule further contributed to the deficiency.
Infection Control Deficiencies in PPE Use and Urinary Bag Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the recertification survey. One significant issue involved a staff member, Cycle Cleaner #1, who did not adhere to the required personal protective equipment (PPE) protocols while cleaning the room of a COVID-19 positive resident. The cleaner was observed entering and exiting the room without wearing gloves or eye protection, and failed to perform hand hygiene after removing their gown. This non-compliance with PPE protocols posed a risk of spreading COVID-19 within the facility. Additionally, the facility did not ensure proper storage and maintenance of urinary drainage bags for two residents. Resident #238's urinary drainage bag was observed hanging in the bathroom without a protective cap on the connection port, and with brown material smeared on the back of the bag. The facility's policy required the use of a cap to prevent contamination, but staff interviews revealed a lack of awareness and adherence to this protocol. Similarly, Resident #52's urinary drainage bag was repeatedly observed resting directly on the floor, contrary to infection control guidelines that mandate keeping the bag off the floor to prevent contamination. These deficiencies highlight a lack of adherence to established infection control policies and procedures, which are critical in preventing the transmission of infections within the facility. The failure to follow proper PPE protocols and ensure the sanitary storage of urinary drainage bags indicates a need for improved staff training and oversight in infection prevention practices.
Dignity and Privacy Violations in Resident Care and Facility Practices
Penalty
Summary
The facility failed to ensure the dignity and privacy of Resident #196 by posting personal care information in a visible area within the resident's room. The resident, who had severe cognitive impairment and was diagnosed with dementia and chronic obstructive pulmonary disease, had a sign on the outside of their closet door indicating specific personal care instructions. This sign was visible to other residents and visitors, which was against the facility's policy that required such information to be discreetly posted inside the closet door. Interviews with staff revealed that the sign was intended as a reminder to prevent the use of briefs, which caused the resident to develop a rash, but staff acknowledged that the visible posting was not dignified. Additionally, the facility used misleading signs on elevators across Units 3, 5, and 6, indicating that the elevators were out of order. These signs were intended to deter cognitively impaired residents from using the elevators, but the elevators were actually functional. The Director of Nursing and other staff members confirmed that the signs were used to prevent confused residents from accessing the elevators, but they did not inform visitors about the true purpose of the signs unless asked. This practice was acknowledged by some staff as potentially confusing and undignified for both residents and visitors. The facility's actions in both instances failed to uphold the residents' rights to a dignified existence and privacy. The visible posting of personal care information and the misleading elevator signs were not in line with the facility's policy on dignity and respect, which emphasized treating residents in a manner that promotes their well-being and self-esteem. Staff interviews highlighted a lack of adherence to these policies, resulting in the identified deficiencies during the survey.
Violation of Resident's Visitation Rights
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing at any time, as required by their visitation policy. The policy allowed residents to have visitors 24/7, subject to the resident's wishes and the protection of other residents' rights. However, the facility restricted a resident's family member from visiting late at night based on the healthcare proxy's wishes, despite the resident's ability to make basic needs known and no documented concerns from the resident about the visits. The resident in question had severe cognitive impairment but was usually able to understand others and express their needs. The resident's care plan emphasized the importance of family involvement, and the resident's preferred activities included visiting with family. Despite this, the facility restricted the resident's adult child from visiting late at night, citing the healthcare proxy's agreement and the discomfort expressed by the resident's roommate. The facility did not document any follow-up with the adult child regarding their request to visit at night, especially given the resident's end-of-life status. Interviews with facility staff revealed inconsistencies in the enforcement of visitation policies. The Social Worker and Administrator acknowledged the facility's doors were locked at night but stated visitors could be allowed for special reasons, such as end-of-life situations. The Social Services Director indicated that the facility did not have set visiting hours and that restrictions should not be based solely on a healthcare proxy's wishes. Despite these statements, the facility restricted the resident's adult child's visits, even though there were no concerns about the adult child being harmful or disruptive during visits.
Deficiencies in Resident Care and Follow-Up
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, as evidenced by deficiencies found during a recertification and abbreviated survey. Specifically, Resident #232, who had bilateral above-the-knee amputations, did not receive timely follow-up on a prosthetics referral. Despite the vascular surgery consultation indicating that the amputation sites were healed and a referral to the prosthetics department was made, there was no documented evidence of an appointment or follow-up communication. Interviews revealed that the unit secretaries were unaware of the referral, and the Registered Nurse Manager acknowledged that the follow-up should have occurred within a couple of weeks. Additionally, Resident #1 experienced an emotionally distressing event that was not addressed in a timely manner. The resident, who had diagnoses including anxiety disorder and cerebral palsy, was startled by a loud noise and flash of light caused by the movement of their bed. Although the resident expressed fear and distress, there was no documented nursing progress note or incident report addressing the event. The resident's representative informed the social worker about the incident a week later, who then updated the care plan. However, the social worker confirmed that they were not immediately notified, and no progress note was written at the time of the incident. The Director of Nursing stated that an incident report was not deemed necessary as the resident was not physically hurt, but acknowledged that emotional distress should have been documented and addressed. The lack of timely follow-up and documentation for both residents highlights a failure in the facility's processes to ensure residents' needs and rights are met, as per their policies on consultation follow-up and adverse incidents.
Improper Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in preventing urinary tract infections. The resident, who had a history of urinary tract infections and resistance to multiple antibiotics, was observed with a leg bag attached to their upper thigh while lying flat in bed and sitting in a wheelchair. This positioning did not allow for gravitational flow of urine, contrary to the facility's policy that required urinary drainage bags to be positioned below the level of the bladder to prevent urine backflow. Interviews with staff revealed a lack of adherence to the facility's policies regarding catheter care. Certified Nurse Aide #47 and Licensed Practical Nurse #49 indicated that leg bags were used for residents who walked, but Resident #238, who had limited mobility, was using a leg bag while in bed and in a wheelchair. The improper positioning of the leg bag was acknowledged by the Infection Preventionist and the Registered Nurse Unit Manager, who confirmed that the incorrect positioning could lead to urine stagnation and infection. The resident had experienced multiple urinary tract infections, some leading to hospitalizations for sepsis.
Failure to Administer RSV Vaccine Timely
Penalty
Summary
The facility failed to ensure that routine and emergency drugs and biologicals were provided to a resident, specifically the respiratory syncytial virus (RSV) vaccine. The resident, who had diagnoses including heart disease, hypertension, and allergic rhinitis, was not administered the RSV vaccine timely after it was ordered in both 2023 and 2024. The facility's policy required that immunization records be reviewed upon admission and that vaccines be offered and administered with consent. However, there was no documented evidence that the vaccine was administered as ordered in 2023, and it was delayed in 2024. Interviews with various staff members revealed a lack of clarity and communication regarding the administration of the vaccine. Licensed Practical Nurses (LPNs) and the Assistant Director of Nursing indicated that vaccines were supposed to be administered within a three-day window, and if not given, they would fall off the Medication Administration Record (MAR) and need to be reordered. The Infection Control Nurse was responsible for obtaining consents and entering orders, but there was no tracking of the RSV vaccine in 2023, leading to it being overlooked. The resident's representative was not informed of the missed vaccine in 2023 until contacted by the Infection Control Nurse in 2024. The Nurse Practitioner, who signed off on the orders, was not notified that the vaccine was not administered as ordered. The lack of administration was attributed to the vaccine order falling through the cracks, and the facility did not have a system in place to ensure follow-up on missed vaccinations, which contributed to the deficiency.
Inadequate Surety Bond Coverage for Resident Funds
Penalty
Summary
The facility failed to ensure that a surety bond was purchased in an amount equal to or greater than the total resident funds deposited with the facility, affecting 239 out of 296 residents with personal funds accounts. The facility's surety bond was for $250,000, which was less than the total amount of resident personal fund accounts held by the facility at various times, with balances ranging from $286,256.24 to $309,980.04. The facility's policy on resident funds did not include a documented policy regarding the surety bond for resident funds. Interviews with facility staff revealed a lack of awareness and oversight regarding the surety bond coverage. The Financial Associate and Accounting Manager were not aware of the exact coverage amount, and the Chief Operating Officer admitted to not knowing the consistent balance of the resident accounts. The Corporate Treasurer, responsible for managing the company's banking relationships and insurance aspects, was unaware of the requirement to regularly check that the Resident Funds Account total did not exceed the surety bond. This oversight led to the deficiency noted in the survey.
Mail Delivery and Privacy Deficiency
Penalty
Summary
The facility failed to ensure residents' rights to receive mail were maintained, affecting all 296 residents. During the recertification survey, it was found that mail was not delivered to residents on Saturdays, as social workers, who were responsible for mail distribution, did not work on weekends. This resulted in residents having to wait until Monday to receive their mail, which is a violation of their rights. Additionally, some residents reported that their mail was opened before being delivered to them, further infringing on their rights to privacy. Interviews with staff revealed inconsistencies in the mail delivery process. Certified Nurse Aides were unaware of the mail distribution process, and there was confusion about who was responsible for delivering mail on weekends. The front desk staff sorted mail by floor, and social workers were supposed to deliver it. However, on Saturdays, the nursing supervisor was tasked with delivering personal mail, while other mail was held until Monday. The Director of Social Work acknowledged that residents should receive their mail on Saturdays and that the current process was unfair, as it denied residents the same rights as other citizens.
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 152 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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 Auburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Auburn Rehabilitation & Nursing Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Finger Lakes Center For Living | 1.9 mi | ★★★★★ | 4 | 3 |
| Seneca Nursing & Rehabilitation Center, Llc | 13.5 mi | ★★★★★ | 0 | 0 |
| Northwoods Rehab And Nursing Center At Moravia | 16.2 mi | ★★★★★ | 14 | 0 |
| Syracuse Home Association | 19.6 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Commons On St Anthony, A S N F & Short T R C.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.