Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vestal Park Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with schizoaffective disorder did not receive their prescribed antipsychotic medication, olanzapine, for several days. The facility failed to notify the resident's physician and representative about the missed doses, contrary to their policy. Interviews revealed that the nursing staff did not document the missed doses or inform the necessary parties, leading to a deficiency in care.
A resident with schizo-affective disorder did not receive twenty doses of their prescribed anti-psychotic medication, olanzapine, due to a lack of communication and documentation by the facility staff. The medication was returned to the pharmacy without explanation, and the physician was not informed of the unavailability, which could have led to a change in the treatment plan.
The facility failed to ensure that licensed nurses and CNAs had the necessary competencies to care for residents, as identified through assessments and care plans. An LPN left medications at a resident's bedside without a physician's order, and a CNA entered a room under transmission-based precautions without proper PPE or hand hygiene. Agency staff did not receive formal orientation or competency evaluations, and there was no documented evidence of infection control training for some staff.
The facility failed to maintain proper food storage and preparation temperatures, with chicken salad found at unsafe temperatures in the cooler. Additionally, the dishwasher did not meet required wash and rinse temperatures, with the Food Service Director failing to address the issue despite documented discrepancies.
In a recent survey, a facility was found to have left medications unattended in the rooms of three residents, none of whom had been assessed or authorized to self-administer their medications. One resident with a history of stroke and impaired cognition had multiple medications left on their bedside table, while another with chronic obstructive pulmonary disease had a nicotine patch and inhaler left unattended. A third resident, with intact cognition, had medications and an inhaler left at their bedside without a self-administration order. Nursing staff acknowledged the practice was against policy, and the Director of Nursing confirmed the facility's policy required a thorough assessment and physician order for self-administration.
A resident with chronic kidney disease and dementia was observed with an uncovered urinary catheter drainage bag, visible in both their room and public areas, violating the facility's dignity policy. Staff interviews confirmed the expectation to cover catheter bags, highlighting a lapse in adherence to dignity and infection control standards.
Two residents in the facility did not receive necessary assistance with activities of daily living, leading to deficiencies in personal hygiene and dignity. One resident, with osteoporosis and depression, was not shaved despite needing assistance, while another resident, with a history of stroke and hemiparesis, did not receive a shower for three weeks and had poor oral hygiene. Staff interviews revealed a lack of awareness and documentation, highlighting systemic issues in care delivery and communication.
The facility failed to provide residents with palatable and properly tempered meals, as observed during a survey. Meals were served at incorrect temperatures, with hot foods being cold and cold foods being warm. Residents reported the food lacked flavor and items were often missing from trays. Staff interviews confirmed these issues, highlighting a failure in maintaining food quality and temperature standards.
A long-term care facility failed to maintain an effective infection prevention and control program. A CNA did not follow transmission-based precautions for a resident with Clostridium difficile, entering the room without proper PPE and neglecting hand hygiene. Additionally, an RN did not change gloves or perform hand hygiene during wound care for a resident with a Stage 3 pressure ulcer, risking cross-contamination. These actions were contrary to the facility's infection control policies.
The facility failed to develop comprehensive care plans for residents, omitting critical treatments like anticoagulants and insulin, and lacking specific interventions for behavioral symptoms. This deficiency was identified during a survey, revealing gaps in addressing residents' medical and psychosocial needs.
The facility failed to consistently post daily nurse staffing information at the beginning of each shift, as required. Observations during a survey revealed that the staffing information was often outdated or missing. Interviews with staff highlighted a lack of clarity and consistency in the process, with no documented policy to ensure accurate and timely posting.
The facility failed to properly label and store medications, as insulin pens lacked opened dates, a medication refrigerator had incomplete temperature logs, and a treatment cart was found unlocked. These deficiencies were observed during a survey, with staff acknowledging the lack of routine checks and the importance of securing medications to prevent resident access.
Two residents experienced deficiencies in meal tray accuracy, with missing or incorrect food items not aligning with their dietary needs and preferences. One resident with multiple sclerosis and dysphagia did not receive items listed on their meal ticket, while another resident with diabetes and hypertension received incorrect bread and vegetables. The facility's policy for meal tray accuracy was not effectively implemented, leading to these deficiencies.
A resident with severe cognitive impairment and high fall risk had their call bell consistently out of reach, contrary to facility policy. Observations showed the call bell behind the bed or on the floor, and staff interviews confirmed the resident's inability to communicate needs, highlighting the importance of accessible call bells.
Failure to Notify Physician and Representative of Missed Medication
Penalty
Summary
The facility failed to notify the resident's physician and representative when there was a significant alteration in treatment for a resident diagnosed with schizoaffective disorder. The resident was prescribed olanzapine, an antipsychotic medication, which was not administered for multiple days in November and December 2023. Despite the facility's policy requiring notification of the physician and resident representative in such cases, there was no documented evidence that this was done. The resident's medication was returned to the pharmacy without explanation, and the nursing staff did not document the missed doses or notify the appropriate parties. Interviews with facility staff and the resident's representative revealed that the nursing staff did not inform the physician or the resident's representative about the unavailability of the medication. The resident's representative, who visited almost daily, was unaware of the missed doses until the resident complained of insomnia. The Director of Nursing and the attending physician were also unaware of the issue, and both stated that they expected to be notified of such occurrences. The failure to administer the medication and notify the necessary parties led to a deficiency in the facility's care for the resident.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident received their prescribed anti-psychotic medication, olanzapine, as ordered by their physician. The resident, who had diagnoses including schizo-affective disorder, was not administered twenty doses of olanzapine over several days in November and December 2023. The facility's policies required that any changes affecting a resident's medication be communicated to the physician, and that efforts be made to ensure medications were available. However, there were no nursing notes documenting the missing medication or any notification to the provider. The resident's olanzapine was delivered to the facility and signed for by an LPN, but it was later returned to the pharmacy without documentation explaining why. Interviews with facility staff, including a nurse practitioner and the Director of Nursing, revealed that they were unaware of the missing medication and expected nursing staff to notify them of such issues. The Director of Nursing acknowledged that the resident did not receive the medication for several days and stated that the facility lacked a system to track returned medications. The failure to administer the medication was not communicated to the resident's physician, who stated they would have adjusted the treatment plan if informed. The physician noted that missing doses of olanzapine could lead to the return of symptoms such as hallucinations or psychosis. The facility's lack of documentation and communication regarding the unavailability of the medication contributed to the deficiency.
Deficiency in Staff Competency and Training
Penalty
Summary
The facility failed to ensure that licensed nurses and certified nurse aides possessed the necessary competencies and skills to meet the needs of residents as identified through assessments and care plans. Specifically, four licensed nurses and two certified nurse aides were found lacking in documented competencies and education. One LPN left medications at a resident's bedside without a physician's order for self-administration and had not received an annual competency evaluation for medication administration. Additionally, a CNA entered a resident's room under transmission-based precautions without proper personal protective equipment or performing appropriate hand hygiene, with no documented evidence of infection control training. The facility's policies outlined the responsibilities of the Staff Development/Nurse Educator in supervising training programs for new nursing personnel and the orientation program for new hires. However, there was no documented evidence of a policy and procedure for competency evaluations. The facility assessment indicated that competencies and training were to be conducted upon hire, annually, and as needed, but this was not reflected in the records for the involved staff. The facility relied on agency nursing staff to provide direct care during the survey period, but these staff members did not receive formal orientation or competency evaluations from the facility. Interviews with various staff members, including unit managers and the nurse educator, revealed that agency staff were not provided with general orientation or competency assessments, and there was uncertainty about how the facility ensured their competency. The Director of Nursing confirmed that agency staff did not receive orientation, only a brief report from unit managers.
Food Safety and Dishwasher Temperature Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an observation in the main kitchen, chicken salad was found in the walk-in cooler at a temperature of 52 degrees Fahrenheit, which is above the safe temperature for potentially hazardous foods. The chicken salad was prepared by a prep cook who stated it had been made about 10 minutes prior. The Food Service Director indicated that potentially hazardous food could be left out of temperature during necessary preparation for up to 2 hours. However, the chicken salad only cooled to 47 degrees Fahrenheit after nearly 2 hours and was then placed in the walk-in freezer to cool rapidly, eventually reaching a safe temperature of 41 degrees Fahrenheit. Additionally, the facility's mechanical dishwasher was not maintaining the required temperatures for washing and rinsing. The dishwasher's wash temperature was observed at 157 degrees Fahrenheit and the final rinse temperature at 171 degrees Fahrenheit, both below the required specifications. The Food Service Director acknowledged that the log documented several days of recorded temperatures below the required levels but did not take corrective action, relying instead on the log sheet temperatures. The dishwasher was not serviced despite the discrepancies, as service personnel claimed it was functioning properly and just took time to reach the required temperature.
Unattended Medications Pose Safety Risk
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by leaving medications unattended in the rooms of three residents, none of whom had been assessed or authorized to self-administer their medications. Resident #127, with a history of stroke and moderately impaired cognition, had multiple medications left on their bedside table by a nurse, despite not having an order to self-administer. The resident expressed concern about the practice, noting that medications should not be left with patients as they could be forgotten or taken by someone else. The nurse admitted to leaving the medications due to habit, despite knowing it was against policy. Resident #148, who had moderately impaired cognition and a history of chronic obstructive pulmonary disease, also had medications left unattended. An unused nicotine patch and an inhaler were found on their bedside table, contrary to the facility's policy. The resident reported that this was a recent change in practice, with different nurses leaving medications at the bedside. The nursing staff confirmed that the resident did not have a self-administration order and acknowledged the risks of leaving medications unattended. Resident #146, with intact cognition and a history of chronic obstructive pulmonary disease, had medications and an inhaler left at their bedside without a self-administration order. The resident expressed discomfort with the practice, noting that they sometimes received incorrect medications and discarded those they deemed unnecessary. Nursing staff were aware of the situation but failed to follow up with the physician or update the care plan to reflect the resident's needs. The Director of Nursing confirmed that the facility's policy required a thorough assessment and physician order for self-administration, which had not been followed in these cases.
Uncovered Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter drainage bag was covered, compromising the resident's dignity and privacy. Specifically, Resident #71, who had chronic kidney disease, dementia, and urinary retention, was observed with an uncovered urinary catheter drainage bag on multiple occasions. The facility's policy on Quality of Life-Dignity, revised in March 2024, required that residents be treated with dignity and respect, which included keeping urinary catheter bags covered. Despite this policy, the resident's catheter bag was visible from the hallway and in public areas, such as the day room, where other residents and staff were present. Interviews with facility staff, including a Certified Nurse Aide, a Registered Nurse Unit Manager, and the Director of Nursing, confirmed that the uncovered catheter bag was a dignity issue and that staff were expected to cover catheter bags. The staff acknowledged that the failure to cover the catheter bag was not only a dignity issue but also an infection control concern. The observations and interviews indicated a lack of adherence to the facility's policy, resulting in the deficiency noted during the survey.
Deficiencies in Personal Hygiene and Dignity for Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for two residents, leading to deficiencies in personal hygiene and dignity. Resident #88, who had diagnoses of age-related osteoporosis, tremors, and depression, required supervision and touch assistance for personal hygiene. Despite this, the resident was observed with dark facial hair on multiple occasions and expressed dissatisfaction with not being shaved, which was confirmed by a Certified Nurse Aide who acknowledged the oversight and recognized it as a dignity issue. Resident #127, with a history of cerebral vascular accident, hemiplegia, hemiparesis, and depression, required substantial assistance for bathing and oral hygiene. The resident reported not having a shower in three weeks and expressed a desire for proper bathing instead of being wiped down. Observations confirmed the resident's poor oral hygiene and unchanged clothing, and interviews with staff revealed a lack of awareness and documentation regarding the resident's unmet needs, highlighting a failure in care delivery and communication. Interviews with staff, including Certified Nurse Aides and Registered Nurse Unit Managers, revealed systemic issues in ensuring that care plans were followed and documented. The Director of Nursing emphasized the importance of adhering to personalized care plans, but the lack of documentation and follow-up by Unit Managers contributed to the deficiencies observed. These failures in providing adequate care and maintaining resident dignity were identified during the survey, underscoring the need for improved oversight and adherence to care protocols.
Deficiency in Food Service Quality and Temperature
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable, flavorful, and at appetizing temperatures during the recertification and abbreviated surveys conducted from July 22 to July 26, 2024. Observations and interviews revealed that meals served on July 23 and July 24 were not at appropriate temperatures, with hot foods being served cold and cold foods being served warm. Residents reported that the food lacked flavor and was often cold, requiring reheating in microwaves. Specific issues included pork being overcooked and tough, stuffing tasting bland, and fish being served at an unacceptable temperature of 96 degrees Fahrenheit. Additionally, residents complained about missing items from their meal trays, such as nutritional supplements and silverware. Interviews with Certified Nurse Aides and the Food Service Director highlighted systemic issues in meal preparation and delivery. The Food Service Director acknowledged that test trays were supposed to be completed three times a week, but the results were not meeting the required standards. The director also confirmed that hot food should be served above 135 degrees Fahrenheit and cold food between 33-41 degrees Fahrenheit, which was not adhered to during the observed meals. The deficiencies in food service were corroborated by multiple residents and staff, indicating a failure in maintaining food quality and temperature as per the facility's policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Certified Nurse Aide #12 and Registered Nurse #15. Certified Nurse Aide #12 did not adhere to the required transmission-based precautions for a resident diagnosed with Clostridium difficile. The aide entered the resident's room without donning the necessary personal protective equipment, such as a gown and gloves, and failed to perform appropriate hand hygiene upon exiting the room. This was despite the facility's policy that required such precautions to prevent the spread of infection. Additionally, Registered Nurse #15 did not follow proper hand hygiene protocols during wound care for a resident with a Stage 3 pressure ulcer. The nurse did not change gloves or perform hand hygiene after removing a soiled dressing and before applying a clean dressing. This action was contrary to the facility's policy on standard precautions, which required changing gloves between tasks to prevent cross-contamination and potential infection. The deficiencies were observed during a recertification survey, where it was noted that the facility's staff, including Certified Nurse Aide #12 and Registered Nurse #15, did not consistently follow the established infection control policies. Interviews with staff revealed a lack of understanding and adherence to the infection control protocols, highlighting a gap in the facility's training and education efforts regarding infection prevention and control measures.
Deficiency in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, as identified during a recertification survey. Specifically, the care plans for two residents did not include the use of anticoagulants or insulin, which are critical for managing their medical conditions such as pulmonary embolism and diabetes. Another resident's care plan lacked specific interventions for managing behavioral symptoms associated with dementia, despite frequent occurrences of yelling, crying, and signs of anxiousness. Resident #83, with diagnoses including pulmonary emboli and diabetes, was receiving daily insulin injections and an oral anticoagulant. However, there was no documented evidence of a comprehensive care plan addressing these treatments. The resident experienced a medical incident involving coffee ground emesis and was sent to the emergency room, highlighting the need for a detailed care plan. Interviews with staff revealed that while they were aware of the resident's diabetic condition, they were not informed about the anticoagulant use, which is crucial for monitoring potential side effects like bleeding. Resident #69, diagnosed with dementia and depression, exhibited frequent behavioral symptoms such as yelling and crying. Despite these behaviors being documented in nursing progress notes, the care plan only included generic interventions without specific strategies tailored to the resident's needs. Staff interviews indicated a lack of awareness of specific care plan interventions for managing the resident's behavioral symptoms, underscoring the deficiency in providing person-centered care.
Inconsistent Posting of Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post daily nurse staffing information at the beginning of each shift, as required by regulations, during a recertification survey conducted over five days. Observations revealed that the staffing information was not updated daily and was often outdated or missing entirely. For instance, on multiple occasions, the posted staffing document was either dated incorrectly or lacked complete information for the evening and overnight shifts. On some days, there was no staffing document posted at all. Interviews with facility staff, including the receptionist, Staffing Coordinator, Registered Nurse Supervisors, and the Director of Nursing, highlighted a lack of clarity and consistency in the process of posting staffing information. The responsibility for posting the staffing information was reportedly shared among various staff members, including the building Supervisor, Staffing Coordinator, and Director of Nursing. However, there was no documented policy or procedure to ensure the information was posted accurately and timely, leading to the observed deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed during a recertification survey. Specifically, the Brookside Garden medication cart contained insulin pens without opened dates, which is crucial for determining the expiration of the medication. Insulin pens for two residents were found without the necessary opened date documentation, posing a risk of administering expired insulin. The responsibility for checking these medications was unclear, with the Licensed Practical Nurse Unit Manager acknowledging the lack of a routine schedule for checking medication carts. Additionally, the medication refrigerator in the Brookside Terrace medication room lacked a complete record of temperature logs for several days, and the temperature was recorded at the upper limit of the acceptable range. The Registered Nurse Unit Manager indicated that it was the overnight nurses' responsibility to check and log the refrigerator temperatures, but acknowledged that anyone accessing the refrigerator could document the temperature. The absence of consistent temperature monitoring could lead to medications being stored outside of the recommended range, potentially compromising their efficacy. Furthermore, the treatment cart on Brookside Terrace was found unlocked on multiple occasions, containing various medications and creams. Both the Licensed Practical Nurse and the Registered Nurse Unit Manager confirmed that the cart should be locked to prevent residents from accessing its contents. The Director of Nursing reiterated the importance of locking treatment carts to secure prescription medications and wound care supplies, emphasizing the potential risk of residents accessing these items.
Deficiency in Meal Tray Accuracy and Resident Dietary Needs
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that meets the daily nutritional needs of residents, as evidenced by missing food items on meal trays for two residents during a recertification survey. Resident #107, who has multiple sclerosis, depression, and dysphagia, reported that food items listed on their meal ticket were often missing, such as crackers with soup. During an observation, Resident #107's meal tray was missing rocky road chocolate pudding and steamed rice, which were listed on their meal ticket, and the resident stated they would have consumed these items if they had been provided. Resident #148, who has a fractured left femur, diabetes, and hypertension, also experienced discrepancies between their meal ticket and the food received. The resident's meal ticket listed a tuna sandwich on wheat bread, an egg salad sandwich, and broccoli, but they received a tuna sandwich on white bread, no egg salad sandwich, and mixed oriental vegetables instead of broccoli. The resident expressed a preference for wheat bread, and the Food Service Director confirmed that wheat bread was available and substitutions should have been communicated to the resident. The facility's policy required meal tray accuracy checks, but these were not effectively implemented, leading to the deficiencies observed.
Inaccessible Call Bell for Resident with Severe Impairment
Penalty
Summary
The facility failed to ensure that call bells were adequately equipped and accessible to residents, specifically for one resident who was reviewed during the recertification survey. The resident in question had severe cognitive impairment and was dependent on staff for all activities of daily living due to conditions such as epilepsy, a stroke, and aphasia. The facility's policy required that call lights be positioned within reach of residents after care was provided, yet observations showed that the resident's call bell was consistently out of reach on multiple occasions. The deficiency was highlighted through observations and interviews with staff members. On several occasions, the resident's call bell was found behind the bed or on the floor, making it inaccessible. Interviews with a Certified Nurse Aide and a Registered Nurse confirmed that the resident was unable to communicate their needs and was at high risk for falls, emphasizing the importance of having the call bell within reach. The Director of Nursing acknowledged that it was inappropriate for call bells to be out of reach and stated that staff should ensure proper placement during rounds and when leaving the resident's room.
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Illustrative
What surveyors actually found near you
We read the 21 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Vestal
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ideal Senior Living Center | 3.2 mi | ★★★★★ | 6 | 0 |
| Absolut Ctr For Nursing & Rehab Endicott L L C | 4.2 mi | ★★★★★ | 1 | 0 |
| Willow Point Rehabilitation And Nursing Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Susquehanna Nursing & Rehabilitation Center, L L C | 4.9 mi | ★★★★★ | 1 | 0 |
| Good Shepherd Village At Endwell | 6.6 mi | ★★★★★ | 6 | 0 |
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