Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 The Grand Rehabilitation And Nrsg At Chittenango during CMS and state inspections, most recent first.
Surveyors found multiple medication storage and labeling failures in the Unit A med room and Unit A South med cart. Meds were left on the floor, discontinued ceftriaxone and an unlabeled resident Tylenol were stored improperly, the med refrigerator was out of temp with frozen insulin pens/vials and ice buildup, an unlabeled Lantus pen was in a cart drawer, and an LPN handed over med cart and narcotic keys without completing the required narcotic count.
Kitchen food handling and sanitization deficiencies were observed when dietary staff began food prep without washing hands, unlabeled and undated food was stored in coolers, and staff handled food with uncovered beards. Surveyors also observed improper dish and surface sanitizing practices, including incorrect sanitizer testing, inadequate sanitizer use, and a tray-line bucket filled with cleanser instead of sanitizer.
Call Bells Not Kept Within Reach: A resident with dementia and impaired cognition was observed with a call bell on the floor and out of reach, despite a care plan intervention to encourage call bell use for assistance. Several other residents were also observed with call bells out of reach, including one resident calling out for help, and both a CNA and an LPN stated that every resident should have a call bell within reach.
A resident with severe cognitive impairment and Huntington's disease, who required extensive assistance with ADLs, was repeatedly observed with greasy hair, unclean fingernails, soiled clothing, and a dirty wheelchair. Staff interviews and documentation confirmed inconsistent provision of scheduled showers and inadequate hygiene care, resulting in the resident's persistent unkempt appearance.
Two residents experienced deficiencies in nutritional care: one had significant, unaddressed weight loss with no timely intervention or documentation by staff, while another self-administered tube feedings and water flushes without proper supervision, physician order, or care plan authorization. Staff failed to follow facility policies for reporting, monitoring, and documenting nutritional interventions and tube feeding administration.
A resident experienced an unwitnessed fall and subsequent pain, but the LTC facility delayed ordering and obtaining X-ray results, leading to a late diagnosis of a hip fracture. The resident was not medicated for pain, and there was inadequate documentation and assessment following the fall. Interviews revealed systemic issues with fall management and timely medical intervention.
A resident with Alzheimer's and stroke, requiring substantial assistance for toileting, was left in urine-soaked clothing and linen due to staff inaction. The resident's call bell was inaccessible, and care protocols were not followed, leading to a deficiency in maintaining personal hygiene and dignity.
Medication Storage, Labeling, and Controlled Substance Count Failures
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in the Unit A medication room and the Unit A South medication cart. During survey observations, medications were found on the floor in the medication room, discontinued ceftriaxone vials were left in a clear bag, and a resident’s unlabeled personal Tylenol was stored inside an emesis bag. The medication refrigerator in the Unit A medication room was also out of range, and the surveyor observed frozen insulin pens and vials inside it. The refrigerator temperature log showed repeated temperatures below the acceptable range, including readings of 28 degrees Fahrenheit and 30 degrees Fahrenheit, with corrective action documented as temperature adjustments. The Unit A medication room refrigerator also had ice buildup in the freezer and contained vaccines, insulin vials, and rectal suppositories. The LPN Unit Manager stated the refrigerator was used for surplus insulin and that the frozen insulin would need to be discarded, and also stated the room should not have items on the floor and that the unlabeled Tylenol should have been labeled and stored properly. The Unit A South medication cart contained an unlabeled Lantus insulin pen in the top drawer, and an LPN handed medication cart and narcotic keys to another LPN so a locked narcotic cabinet could be opened without completing a narcotic count. Staff interviews confirmed that the keys were handed over without the required narcotic reconciliation. The DON stated medications should be stored properly and labeled, personal medications should be labeled or sent home, refrigerator temperatures should be checked nightly, and nurses should not hand over medication room or cart keys without a proper narcotic medication reconciliation count.
Kitchen Food Handling and Sanitization Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the main kitchen. During an observation on 9/22/2025 at 6:25 AM, Dietary Aide #5 and Dietary Aide #6 began food preparation without being observed washing their hands, and there were no paper towels at either main kitchen handwashing sink. Both sinks were dry when they arrived to work. When asked about the missing paper towels, the staff looked at each other and left the area. Food items were also found unlabeled and undated in kitchen coolers. On 9/22/2025, three unlabeled and undated sandwiches were observed in a 2-door reach-in cooler, and Dietary Aide #5 stated they must have been from the previous evening dinner. Later that morning, two unlabeled pans of sliced meat were observed in the walk-in cooler, and another unlabeled pan of sliced meat was observed there on 9/23/2025. During another observation, [NAME] #9 changed gloves, touched the garbage can, and returned to meal preparation without washing hands until questioned. Food contact surfaces and sanitation practices were also not followed as required. On 9/23/2025, Dietary Aide #11 and [NAME] #9 were observed working with food while their beards were uncovered. During observation of the 3-bay sink and dishwashing process, staff did not follow the documented sanitizing procedures: the sinks were empty, a pan was rinsed in sanitizer for only fifteen seconds, the sanitizer test strip was dipped and removed immediately instead of being read after the required wait time, and a red bucket being used for tray line sanitizing was found to contain cleanser instead of sanitizer, with no sanitizer registering when tested. Staff interviews confirmed that the expected procedures were to wash hands when entering the kitchen and after contamination, label and date leftover food, cover facial hair, and sanitize dishes and food contact surfaces using the proper sink sequence and sanitizer strength.
Call Bells Not Kept Within Reach
Penalty
Summary
A working call system was not kept within reach in residents’ bathrooms and bathing areas, and one resident was found without an accessible means to directly contact staff for assistance. Resident #9 had a diagnosis of dementia, and the 8/24/2025 MDS documented impaired cognition, that the resident was usually understood, and that the resident was dependent for most ADLs. The comprehensive care plan, revised 8/18/2025, documented that the resident required assistance with self-care and included an intervention to encourage use of the call bell for assistance. During observation on 9/22/2025 at 7:39 AM, Resident #9 was in bed and the touch pad call bell was on the floor out of reach. Additional observations showed other residents’ call bells were also not within reach during the survey. On 9/22/2025, Resident #6’s call bell was resting on the lower frame of the bed out of reach, Resident #62’s call bell was on the floor while the resident was calling out for help, Resident #10’s call bell was on the floor under the bed, and Resident #63’s touch pad call bell was on the floor out of reach. Resident #63 was again observed the next day with the call bell still on the floor. During interviews, a CNA and an LPN stated that every resident should have a call bell within reach, and the LPN stated staff had been reminded many times to ensure this occurred.
Failure to Provide Adequate Hygiene and Grooming for Dependent Resident
Penalty
Summary
A resident with Huntington's disease and dementia, who was assessed as having severe cognitive impairment and requiring extensive assistance with activities of daily living, did not consistently receive adequate care to maintain personal hygiene and grooming. Observations over several days revealed the resident had greasy hair, unclean and jagged fingernails with dark matter underneath, food debris on clothing, and a heavily soiled wheelchair. The facility's policy required regular showers or tub baths, thorough washing, drying, and grooming, with documentation of care provided and refusals reported to supervisors. However, records indicated the resident frequently refused or did not receive scheduled showers, and instead received bed baths or partial hygiene. Staff interviews confirmed the resident's unkempt appearance, soiled clothing, and dirty wheelchair. Certified Nurse Aide staff were unsure of the resident's shower schedule and noted the resident was only washed up in the morning, while the LPN Manager stated showers were scheduled weekly and that the resident occasionally resisted care. The LPN Manager also acknowledged the resident's wheelchair was soiled and that spot cleaning should occur, with more frequent hygiene care provided as needed. Despite these requirements, the resident was repeatedly observed in an unclean state, indicating a failure to provide necessary services for activities of daily living as required.
Failure to Maintain Nutritional Status and Supervise Tube Feeding Administration
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, as evidenced by deficiencies in the care of two residents. One resident experienced significant, unaddressed weight loss over several months, with documented weights showing a 12.6% loss in one month and a 9.5% loss over five months. Despite multiple progress notes from medical staff and recommendations for increased fluid intake and nutritional supplements, there was no documented evidence that these interventions were implemented. The resident's poor intake and weight loss were not timely reported to the physician or dietitian, and there was no documentation of a dietitian consultation or new nutritional interventions on the care plan. Staff interviews revealed gaps in communication and monitoring, with nursing and dietary staff each assuming the other was responsible for follow-up and documentation. Another resident, who was dependent on tube feeding for nutrition, was observed self-administering their feedings and water flushes without direct supervision or a physician order authorizing self-administration. The resident was seen administering incorrect amounts of formula and water, and the care plan did not reflect that the resident was permitted to self-administer. Nursing staff signed off on medication administration records as if the correct procedures were followed, but direct observation showed that the resident was not receiving the prescribed amounts. Staff interviews confirmed that supervision was inconsistent and that required documentation and orders for self-administration were missing. Facility policies required that significant weight loss be reported and addressed by the interdisciplinary team, and that tube feedings and medication administration be performed according to physician orders, with proper documentation and supervision. In both cases, these policies were not followed, resulting in unaddressed nutritional risks and deviations from prescribed care. The deficiencies were identified through record review, staff and resident interviews, and direct observation during the survey.
Delayed Response to Resident Fall and Pain Management
Penalty
Summary
The facility failed to ensure that Resident #5 received timely and appropriate treatment and care following an unwitnessed fall. The resident, who had diagnoses including pneumonia, chronic obstructive pulmonary disease, and muscle weakness, was found on the floor during room checks. Despite the resident's complaints of pain the following morning, an X-ray was not ordered until several hours later, and the results were delayed, leading to a significant delay in diagnosing a right hip fracture. The resident was not medicated for pain during this period, and there was a lack of documentation regarding the assessment and follow-up care. The facility's Falls Prevention Program policy required timely assessment and documentation of falls, but there was no evidence of a documented assessment by the on-call medical provider after the fall. The resident's pain and limited mobility were not adequately addressed, and the X-ray results were not promptly communicated to the facility. The delay in obtaining and acting on the X-ray results contributed to the resident's prolonged pain and delayed transfer to the hospital for necessary treatment. Interviews with facility staff revealed systemic issues with the handling of falls and the timeliness of X-ray results. Licensed Practical Nurses expressed discomfort with conducting assessments beyond their scope of practice, and there were inconsistencies in the availability of Registered Nurse Supervisors to perform in-person assessments. The facility's process for handling falls and obtaining timely medical interventions was inadequate, resulting in a failure to provide appropriate care for Resident #5.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. Specifically, the resident, who had diagnoses including Alzheimer's Disease and cerebrovascular accident, required substantial assistance for toileting hygiene and was frequently incontinent of urine and always incontinent of stool. Despite these needs, the resident was not on a toileting program and was left in urine-soaked clothing and linen for an extended period. During the survey, it was observed that the resident's room had a strong odor of urine and stool, and the resident was found in a low bed with their head hanging off the side, indicating a lack of proper positioning and care. The call bell, which should have been within reach, was wedged behind the headboard, making it inaccessible. Licensed Practical Nurse #4 was notified of the resident's condition but delayed attending to the resident, and when they did, they only repositioned the resident without addressing the incontinence issue. Interviews with staff revealed that the resident was supposed to be checked every 45 minutes and offered toileting every 2 hours, but these protocols were not followed. Certified Nurse Aide #5, who was assigned to the resident, was instructed not to wake the resident until lunch, resulting in no care being provided in the morning. The Director of Nursing confirmed that all residents should have their call bells within reach and be checked and changed every 2 hours, highlighting the facility's failure to adhere to its own policies and procedures, leading to the deficiency.
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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 Chittenango
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Onondaga Center For Rehabilitation And Nursing | 6.8 mi | ★★★★★ | 22 | 2 |
| Sunnyside Care Center | 9.4 mi | ★★★★★ | 14 | 0 |
| Jewish Home Of Central New York | 10.5 mi | ★★★★★ | 19 | 0 |
| Oneida Health Rehabilitation And Extended Care | 11 mi | ★★★★★ | 20 | 0 |
| Nottingham R H C F | 11.4 mi | ★★★★★ | 7 | 0 |
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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.