Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Onondaga Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with a history of falls and multiple medical conditions experienced an unwitnessed fall and was found on the floor by a roommate. Although LPNs and CNAs checked the resident's vitals and safety, there was no documented assessment by a qualified professional, such as an RN or via telehealth, as required by facility policy. The resident's care plan indicated a need for assistance with toileting and mobility, but the required post-fall assessment was not completed or documented.
Surveyors found that two residents did not receive adequate supervision or accident prevention measures as required by their care plans. One resident on aspiration precautions was left unsupervised during meals and given a straw, contrary to orders, while another resident at risk for falls did not have fall mats in place and could not reach their call light. Staff interviews and observations confirmed these deficiencies in supervision and implementation of safety interventions.
A resident with Parkinson's and anxiety was physically abused by an LPN, who pushed them into a wall, causing a nosebleed and fractured nose. The resident's care plan noted behavioral symptoms, but the LPN's response was abusive. Witnesses confirmed the incident, leading to the LPN's arrest and charges of assault and endangering a vulnerable adult.
The facility failed to treat residents with respect and dignity, including incidents of staff having a verbal confrontation in front of a resident, standing over a resident while feeding, not timely removing a disruptive resident, and entering a legally blind resident's room without announcing themselves.
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents, with issues including used incontinence briefs left in rooms, broken door handles, missing light fixture covers, exposed wiring, and serving cold beverages in disposable cups. Staff interviews confirmed these practices were not in line with facility policies.
The facility failed to ensure residents received necessary assistance with activities of daily living, including dressing, bathing, and meal supervision. One resident was observed wearing the same nightgown for three days, another did not receive a shower for three weeks, and a third was left to eat alone without supervision. Staff interviews confirmed these deficiencies, which were contrary to the residents' care plans.
The facility failed to ensure timely meal delivery, with meal trays arriving up to 1 hour and 25 minutes late due to kitchen staffing issues. Interviews with residents and staff confirmed the delays, and the Food Service Director acknowledged the problem, citing staffing shortages as the cause.
The facility failed to maintain an effective infection control program and lacked a comprehensive water management plan. Staff did not adhere to PPE protocols for residents on precautions, and there were inconsistencies in Legionella testing, highlighting significant oversights in maintaining a safe environment.
The facility's main kitchen had several deficiencies, including broken cooler and freezer doors, cracked floor tiles, and water leaks, leading to unsanitary conditions. The cleaning policy was not followed, and there was no documented cleaning schedule. Staff interviews revealed that these issues had persisted for months without proper documentation or repairs.
The facility failed to maintain proper temperatures in unit kitchenette refrigerators, with one labeled out of order and another showing discrepancies between recorded and actual temperatures. Staff interviews revealed awareness of the issue, but documentation was not provided when requested.
A resident with chronic kidney disease and acute kidney failure did not receive a recommended follow-up appointment with a nephrologist. Despite multiple notes and attempts to schedule the consult, the appointment was never secured, leading to a significant gap in care. The facility's process for scheduling and tracking consultations was inadequate, resulting in the resident's ongoing dissatisfaction and potential health risks.
The facility failed to provide adequate supervision and a hazard-free environment for two residents. One resident with legal blindness had their bed not in the low position and call bell out of reach, while another resident with dementia was observed wandering unsupervised into other residents' rooms. Staff interviews revealed a lack of adherence to care plans and insufficient monitoring, leading to unsafe conditions.
The facility failed to ensure a resident maintained acceptable nutritional status by not weighing them as ordered, not providing fortified pudding, and not assisting with meals as care planned. The resident had severe protein-calorie malnutrition and required tube feedings and a mechanically altered diet. The resident's weight was not monitored as required, and their nutritional needs were not reassessed. Staff did not consistently assist the resident with eating, leading to low meal intakes.
A resident with end-stage renal disease was found with lidocaine-prilocaine cream at their bedside without a documented assessment for self-administration. The facility's policy required such an assessment, but it was not conducted. Staff interviews confirmed that medications should not be kept at the bedside without a physician order, which was absent in this case.
A resident with dementia and depression, who required an interpreter due to a language barrier, did not have a comprehensive care plan addressing their communication needs or potential victimization risk. Observations showed the resident was not understood by staff, leading to frustration and aggressive behavior. Staff lacked awareness and access to communication tools, despite facility policies on translation services and resident rights.
The facility failed to provide individualized activity programs for two residents, resulting in a deficiency in meeting their physical, mental, and psychosocial well-being. One resident, with depression and an amputation, was not engaged in activities of their choosing due to discomfort and lack of in-room activities. Another resident, with dementia, was observed sitting in the hallway without staff interaction or activities, despite having a care plan that included interests like music and animals. The Activities Director acknowledged insufficient one-to-one visits and ineffective use of the daily chronicle.
A resident with end-stage renal disease did not receive appropriate dialysis care as their dialysis access site dressing was not removed by nursing staff as ordered. The resident had to remove the dressing themselves before their next dialysis session. The facility lacked documented hemodialysis agreements or procedures, and nursing staff failed to monitor the access site properly, leading to a deficiency identified during a survey.
A survey found that a facility failed to properly label and store medications, including insulin pens and an inhaler, on a medication cart. The medications lacked opened or expiration dates, which could affect their effectiveness. An LPN and RN Unit Manager acknowledged the oversight, with the RN confirming monthly audits for expired medications. A pharmacist later clarified the expiration period for the inhaler.
The facility failed to serve food at appropriate temperatures, with test trays showing beef stew and vegetables below required temperatures and French fries cold and undercooked. The Food Service Director acknowledged the issue, citing the lack of plate warmers, and the facility could not provide documentation of test trays.
A resident with dementia and diabetes was served a meal inconsistent with their physician-ordered mechanical soft diet, containing large chunks of beef instead of ground beef. Staff interviews revealed lapses in checking meal consistency, leading to the resident receiving a regular diet meal instead of the required modified diet.
A resident's call bell was repeatedly found out of reach, preventing them from contacting staff for assistance. Despite the facility's policy requiring call bells to be accessible, observations during a survey revealed the call bell on the floor multiple times. Staff interviews confirmed the importance of having the call bell within reach, especially for residents like this one, who had moderately impaired cognition and were dependent on staff for daily activities.
The facility failed to maintain an effective pest control program, leading to evidence of mice in a resident room. A resident reported recent mouse sightings, confirmed by their roommate. Inspection revealed rodent droppings and chewed wrappers inside the heater, which had an open hole allowing pest entry. The Administrator noted that housekeeping and maintenance were responsible for pest management.
Failure to Ensure Qualified Assessment After Resident Fall
Penalty
Summary
A deficiency was identified when a resident with a history of falls, chronic obstructive pulmonary disease, hypertension, and anxiety disorder experienced an unwitnessed fall in the evening. The resident was found on the floor by their roommate, and staff documented that vital signs were taken and were stable, with no signs of injury at the time. However, there was no documented evidence that a qualified professional, such as a registered nurse, assessed the resident after the fall, as required by facility policy and professional standards of practice. The facility's Falls Management and Prevention policy required a head-to-toe assessment by a qualified individual following any fall. Documentation from multiple staff members, including certified nurse aides and LPNs, indicated that the resident was checked for safety and vitals were taken, but the assessment by a registered nurse or through telehealth was not completed or documented. Staff interviews revealed that there was no registered nurse in the building during the shift, and although the process was to contact an on-call RN or use telehealth for assessment, this was not done for the resident in question. The resident had a care plan indicating a risk for falls and required assistance with toileting and mobility. Despite these interventions, the resident attempted to toilet independently, resulting in a fall. The lack of a documented assessment by a qualified professional after the incident constituted a failure to provide care in accordance with the resident's care plan and professional standards. The resident expired the following morning, but the report does not link the death directly to the deficiency.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
Surveyors identified deficiencies in the facility's supervision and accident prevention practices for two residents. One resident with diagnoses including dysphagia, dementia, and acute respiratory failure was on aspiration precautions, requiring a mechanical soft diet, nectar thick liquids, no straws, and partial assistance at meals. Despite these orders and care plan instructions, the resident was observed left alone with their meal tray, not assisted as required, and provided a straw by staff. Multiple staff interviews confirmed a lack of clarity and communication regarding who was responsible for assisting the resident, and staff did not consistently follow the aspiration precaution protocols, including supervision during meals and avoidance of straws. Another resident, with a history of diabetic neuropathy, cataracts, obesity, and a documented risk for falls, did not have all planned fall interventions in place. Observations over several days showed that the resident's bed was not consistently in the lowest position, fall mats were not always in place as care planned, and the call light was frequently out of reach, sometimes on the floor under the bed. The resident reported being unable to get help when needed due to the inaccessible call light. Staff interviews revealed inconsistent understanding and implementation of the care plan interventions, with fall mats not always replaced after meals and the call light not reliably positioned within reach. The facility's failure to ensure adherence to individualized care plans and physician orders resulted in residents not receiving adequate supervision or the necessary interventions to prevent accidents. The lack of proper meal assistance and aspiration precautions for one resident, and the absence of required fall prevention measures for another, were directly observed and confirmed through staff interviews and record reviews.
Resident Abuse by LPN Results in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, resulting in harm. The incident involved a resident with a history of Parkinson's Disease, osteopenia, and anxiety, who was known to exhibit behavioral symptoms such as physical outbursts and frequent requests for anxiety medication. On the day of the incident, the resident approached an LPN to ask about anxiety medication. The LPN, in response, pushed the resident into a wall, causing a nosebleed and a fractured nose. This action was witnessed by multiple staff members and another resident, who reported the incident to the Director of Nursing. The resident's care plan had documented their behavioral symptoms and included interventions such as medication management, psychiatric evaluation, and redirection to a less stimulating environment. Despite these measures, the resident's anxiety had reportedly increased, leading to more frequent aggression towards staff. On the day of the incident, the resident's behavior was consistent with their documented history, yet the LPN's response was inappropriate and abusive, resulting in physical harm to the resident. The incident was reported to the facility's administration, and an investigation was initiated. Witnesses corroborated the resident's account of being pushed into the wall by the LPN. The police were notified, and the LPN was subsequently arrested and charged with assault and endangering the welfare of a vulnerable adult. The facility's failure to prevent this abuse highlights a significant deficiency in protecting residents from harm.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility did not ensure residents were treated with respect and dignity, impacting six residents. Specifically, an activities aide and an LPN had a verbal confrontation in front of a resident after running out of portable oxygen during a group activity. Additionally, a CNA stood over a resident while assisting them with eating, which was against the facility's policy of being at eye level to ensure comfort and proper visualization of chewing and swallowing. Two anonymous residents also reported being told they could not leave their rooms due to a lack of portable oxygen, which restricted their freedom and self-determination. Another resident exhibited continuous disruptive verbal behaviors in a common area and was not removed timely as planned. The resident was also transported in their wheelchair facing backward by a CNA, which was not dignified or respectful. The facility's policy required residents exhibiting behavioral symptoms to be moved to a quiet, controlled space to calm down, but this was not followed. Interviews with staff confirmed that the resident's behavior was disruptive and should have been managed more appropriately. A legally blind resident experienced a lack of respect for their condition when a CNA entered their room without knocking or announcing themselves. The CNA proceeded to reposition the resident without explaining the actions being taken, which left the resident feeling disoriented and uncomfortable. The facility's policy required staff to knock and introduce themselves before entering a resident's room, especially for those with visual impairments, to maintain a homelike environment and ensure the resident's comfort and dignity.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in both the North and South units, as well as the main dining room. On the North unit, surveyors observed used incontinence briefs on the floor and nightstand in resident rooms, a resident who smelled of urine, a broken door handle with sharp edges, and improperly maintained sliding glass door restrictors. Interviews with staff confirmed that used briefs should not be left in resident rooms and that door handles and restrictors should be properly maintained to ensure safety and dignity for residents. On the South unit, surveyors found missing light fixture covers, open light sockets with exposed wiring, and broken door handles in resident rooms. Additionally, there was tape on windows and sliding doors, which had been in place for 1-2 years without proper documentation. Staff interviews revealed that broken equipment should be reported and fixed promptly, and that the tape on windows was not documented or addressed appropriately. In the main dining room, a severely broken table was observed, and residents were served cold beverages in disposable cups, which was not considered homelike. The Food Service Director acknowledged that disposable dishes should only be used in emergencies and that the practice was due to short staffing. Interviews with housekeeping and administrative staff confirmed that broken items should be reported and removed to maintain a safe and clean environment for residents.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
The facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, Resident #1 was observed multiple times over three days wearing the same nightgown, indicating a lack of assistance with dressing. Certified nurse aides confirmed that the resident required assistance with dressing due to poor vision and should have received clean clothing daily, but this was not consistently provided. The resident's care plan and Kardex indicated the need for daily dressing assistance, which was not adhered to by the staff, leading to improper hygiene and potential risk for infection. Resident #12, who required substantial assistance with bathing, reported not receiving a shower until three weeks after admission. The resident's care plan specified shower days twice a week, but the certified nurse aide documentation did not reflect this schedule. Interviews with staff revealed that the resident had not refused care, and the lack of showers was due to time constraints and oversight. This failure to provide regular showers compromised the resident's hygiene and dignity. Resident #35, who required supervision with eating and assistance with transfers, was observed eating alone in their room without supervision on multiple occasions. The resident's care plan indicated the need for supervision during meals and assistance with getting out of bed daily. Staff interviews confirmed that the resident was not consistently offered assistance to get out of bed and was left to eat alone, contrary to the care plan. This lack of supervision and assistance could lead to further health complications and a decline in the resident's condition.
Delayed Meal Service Due to Staffing Issues
Penalty
Summary
The facility did not ensure that each resident received at least three meals daily at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plans of care. Specifically, meal trays were delivered to nursing floors up to 1 hour and 25 minutes after the scheduled mealtimes. The facility's policy on meal service, revised in April 2022, documented that meals would be delivered promptly to assure quality. However, observations on both the North and South Units showed significant delays in meal delivery times, with breakfast carts arriving much later than the scheduled times on multiple occasions. Interviews with residents and staff revealed that the delays were due to the kitchen being short-staffed. A resident mentioned that meals sometimes came late because of staffing issues in the kitchen. Licensed practical nurses and diet technicians confirmed that meals were often late and that the nursing units were not informed of these delays. The Food Service Director acknowledged the staffing issues and stated that they had been told it was acceptable for the North Unit to be served later than scheduled. The registered dietitian, who worked remotely, did not provide oversight to the foodservice staff, further contributing to the issue. The facility failed to adhere to its posted mealtime schedule, resulting in residents receiving their meals late.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in deficiencies for two residents and a lack of a water management plan to reduce the risk of Legionella. Specifically, staff did not adhere to required personal protective equipment (PPE) protocols for residents on transmission-based and enhanced barrier precautions. Resident #45, who had pneumonia and a central line catheter, was observed without proper signage or PPE outside their room. Staff members were seen entering and exiting the room without performing hand hygiene or wearing the necessary PPE, such as gowns and masks. This non-compliance was observed multiple times, indicating a systemic issue in following infection control protocols. Resident #36, who had sepsis and extended-spectrum beta-lactamase resistance, was also not properly managed under enhanced barrier precautions. Staff members were observed entering the resident's room without performing hand hygiene or wearing gowns, despite the presence of an enhanced barrier precaution sign. The staff's lack of awareness and adherence to the required precautions further highlighted the facility's failure to implement an effective infection control program. Additionally, the facility did not have a comprehensive water management plan to address the risk of Legionella. The facility's testing in 2022 and 2023 showed inconsistencies, with one positive result in 2022 and two samples rejected in 2023 without clear documentation. The facility's inability to provide a proper water management plan and the lack of follow-up on the rejected samples, especially the one from the same location as the positive result, demonstrated a significant oversight in maintaining a safe environment for residents and staff.
Food Service Safety Deficiencies in Main Kitchen
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. During the recertification survey, several deficiencies were observed, including disrepair and unclean surfaces in the kitchen. The walk-in cooler and freezer doors were broken and could not close completely, leading to frost and puddles of liquid inside. The cooler floor tiles were cracked and covered with loose rubber mats, and there were large brown spills and food debris present. Additionally, water was dripping through a light fixture, and there were leaks over the aisles in the tray line service area, creating puddles that staff had to walk through. The facility's cleaning policy was not followed, as there was no documented evidence of a kitchen cleaning schedule. Interviews with staff revealed that the kitchen had been in disrepair for months, with issues such as a shattered cooler floor, leaking ceiling, and broken freezer door. The Food Service Director and the Administrator acknowledged the problems but lacked documentation for planned repairs. The kitchen was supposed to be cleaned daily, but this was not documented, contributing to an unsafe and unsanitary environment.
Refrigerator Temperature Maintenance Failure
Penalty
Summary
The facility failed to maintain equipment in safe operating condition, specifically regarding the unit kitchenette refrigerators on both the South and North Units. On the South Unit, an upright refrigerator was labeled as out of order and had an internal temperature of 65 degrees Fahrenheit, while the freezer contained frozen food items. A small black refrigerator on the same unit had a door that did not seal properly, resulting in a measured temperature of 41.7 degrees Fahrenheit. On the North Unit, the refrigerator's thermometer read 58 degrees Fahrenheit, and it contained various food items, including cottage cheese, pureed food, tuna sandwiches, and thickened beverages. Despite the temperature log indicating a temperature of 36 degrees Fahrenheit, the actual temperature was significantly higher, suggesting a discrepancy in the recorded data. Interviews with staff revealed that the Food Service Director was aware of the temperature issues and had ordered a replacement refrigerator for the South Unit, which was redirected to the North Unit when its refrigerator also failed to maintain the proper temperature. The Director of Housekeeping and Laundry was uncertain if a maintenance request form had been completed for the faulty refrigerator. Despite the facility's protocol of checking refrigerator temperatures twice daily, documentation regarding the temperature logs and the South Unit refrigerator was not provided when requested by the surveyors. This lack of documentation and failure to maintain proper refrigerator temperatures led to the deficiency noted in the survey.
Failure to Schedule Nephrology Follow-Up for Resident with Chronic Kidney Disease
Penalty
Summary
The facility failed to ensure that Resident #60 received treatment and care in accordance with professional standards of practice. Resident #60, who was admitted with chronic kidney disease and acute kidney failure, had a recommendation for a follow-up appointment with a nephrologist within one week of discharge from the hospital. Despite multiple documented notes from the physician assistant and interdisciplinary team meetings indicating the need for a nephrology consult, there was no evidence that the follow-up appointment was scheduled or occurred. The resident expressed frustration over the delay and dissatisfaction with their renal diet, which could not be liberalized without nephrology consultation. The facility's process for scheduling and tracking consultations was inadequate. The registered nurse Unit Manager and the physician assistant both indicated that they expected the consults to be scheduled and followed up on, but there was no clear process for ensuring this happened. The Consultation Tracker showed multiple failed attempts to schedule the nephrology appointment, but there was no documented evidence that the medical provider was informed of these failures. The Director of Nursing acknowledged the issue and mentioned ongoing performance improvement audits, but the deficiency persisted. Interviews with the resident, registered nurse Unit Manager, physician assistant, and Director of Nursing revealed a lack of communication and follow-up regarding the nephrology consult. The resident's care plan included a referral to nephrology, but the necessary appointment was never secured. This failure to follow through on critical medical recommendations resulted in a significant gap in the resident's care, highlighting deficiencies in the facility's processes for managing and tracking specialist consultations.
Failure to Ensure Adequate Supervision and Hazard-Free Environment
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for two residents, leading to deficiencies in care. Resident #379, who had legal blindness and a history of falls, was found with their bed not in the low position and their call bell out of reach on multiple occasions. Despite care plan interventions specifying the need for a low bed and accessible call bell, staff failed to consistently implement these measures. Observations revealed that the resident's bed was often at hip or mid-thigh height, and the call bell was sometimes on the floor, posing a significant fall risk. Interviews with staff indicated a lack of awareness and adherence to the care plan requirements for this resident, highlighting a gap in communication and training regarding fall prevention protocols. Resident #42, diagnosed with dementia and glaucoma, was observed wandering unsupervised into other residents' rooms and beds. The resident's care plan did not include interventions for wandering or risk for victimization, despite their behavior posing potential safety risks. Staff interviews revealed that the resident had been found in other residents' beds and rooms, which could lead to victimization or other safety issues. The care instructions did not document the need for a wander alert device or increased supervision, and staff were unaware of any specific interventions for this resident's wandering behavior. The lack of appropriate monitoring and care plan updates for Resident #42 further demonstrated the facility's failure to provide a safe environment. The facility's policies on falls management and behavior management were not effectively implemented for these residents. The interdisciplinary team did not adequately identify and implement necessary interventions to reduce fall risks and manage wandering behaviors. The deficiencies observed in the care of Residents #379 and #42 indicate a broader issue with the facility's adherence to its own policies and procedures, resulting in unsafe conditions for the residents.
Failure to Maintain Nutritional Status and Provide Meal Assistance
Penalty
Summary
The facility did not ensure that Resident #75 maintained acceptable parameters of nutritional status. Specifically, the resident was not weighed as ordered, did not receive fortified pudding, and was not assisted with meals as care planned. The resident had a diagnosis of severe protein-calorie malnutrition, dysphagia, and gastrostomy status. The resident's care plan included tube feedings and a mechanically altered diet, but the resident was also supposed to receive pureed solids and honey thick liquids. However, the resident's meal intakes were consistently low, and they were not provided with all the items on their meal tray, such as fortified pudding. The resident's weight was not monitored as required. The resident was weighed on admission and once more on 4/26/2024, showing a weight loss of 2.9 pounds. There were no additional documented weights after 4/26/2024, despite the requirement for weekly weights. The registered diet technician and other staff acknowledged the missing weights and the importance of monitoring the resident's nutritional status. The resident's nutritional needs were not reassessed since admission, and the resident's intake of fortified foods and other nutritional support was not adequately managed. The resident was also not assisted with meals as care planned. Observations showed that the resident's meal trays were often left untouched, and staff did not assist the resident with eating. The care plan documented that the resident was dependent on one person for eating, but staff did not consistently provide the necessary assistance. Interviews with staff revealed that there was a lack of communication and adherence to the care plan, resulting in the resident not receiving the required support during meals.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that a resident's ability to safely self-administer medications was clinically appropriate. Specifically, Resident #45, who had end-stage renal disease and was dependent on hemodialysis, was found with a tube of lidocaine-prilocaine cream at their bedside. There was no documented evidence that the resident was assessed for their ability to self-administer this medication. The facility's policy required an assessment of a resident's mental and physical abilities to determine if self-administration was appropriate, and if not, medications were to be administered by a nurse. However, this assessment was not conducted for Resident #45. Observations during the survey revealed that the resident applied the cream to their dialysis access site before and sometimes after dialysis sessions, with the knowledge of the facility staff. Despite this, there was no physician order for the cream or instructions for self-administration. Interviews with facility staff, including a certified nurse aide and a licensed practical nurse, indicated that medications should not be kept at the bedside without a physician order, and the cream should have been stored in the medication cart. The Regional Registered Nurse confirmed that no order existed for Resident #45 to self-administer medications, and the cream should have been removed from the resident's room.
Failure to Address Language Barrier and Victimization Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a language barrier and potential risk of victimization. The resident, diagnosed with dementia and depression, had a documented need for an interpreter as their preferred language was not English. Despite this, the comprehensive care plan did not include specific interventions for the resident's language barrier or their potential to become a victim of verbal or physical abuse. Observations and interviews revealed that staff were not equipped with the necessary tools or information to effectively communicate with the resident, leading to frustration and aggressive behavior from the resident. During the survey, it was observed that the resident attempted to communicate with staff and other residents but was not understood due to the language barrier. The resident was seen trying to stand unassisted and was harshly yelled at by another resident, with no staff present to intervene. Interviews with staff indicated a lack of awareness and availability of communication tools such as picture charts or telephone translator services, which were supposed to be part of the resident's care plan. Staff members admitted to using gestures and simple language to communicate but were unaware of any specific interventions for the resident's communication needs. The facility's policies on translation services, resident rights, and behavior management were not effectively implemented for this resident. The lack of a comprehensive care plan addressing the resident's language barrier and potential victimization risk resulted in unmet needs and increased frustration for the resident. Staff interviews highlighted the importance of communication tools, yet these were not consistently available or utilized, further exacerbating the resident's communication challenges and behavioral issues.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide ongoing programs to support residents in their choice of activities, as evidenced by the cases of two residents. Resident #13, who has depression and a left lower leg amputation, was not offered meaningful activities of their choosing. Despite having a care plan that included interests such as music, Bingo, and pet therapy, the resident was not engaged in these activities. Observations and interviews revealed that Resident #13 often stayed in bed due to discomfort from their chair and was not provided with in-room activities. The Activities Director acknowledged that one-to-one room visits were lacking, and the resident's refusals to participate in activities were not adequately addressed or care planned. Resident #36, diagnosed with metabolic encephalopathy and dementia, was also not provided with activities that matched their preferences. The resident was observed sitting in the hallway for extended periods without staff interaction or activities being offered. Although the care plan included interests such as music and animals, these were not reflected in the resident's daily routine. The Activities Director admitted that the resident's care plan did not document a family interview and that one-to-one visits were insufficient. The daily chronicle provided to the resident was not effectively utilized, as the resident required assistance to engage with the activities included. Overall, the facility's failure to implement individualized activity programs for these residents highlights a deficiency in meeting the physical, mental, and psychosocial well-being of its residents. The lack of meaningful engagement and the absence of tailored interventions for residents who refuse or are unable to participate in group activities contributed to this deficiency.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident requiring such services, as observed during a recertification survey. The resident, diagnosed with end-stage renal disease and dependent on renal dialysis, had a physician's order to remove the dialysis access site dressing 6-8 hours after dialysis. However, the dressing was not removed as scheduled, and the resident reported having to remove it themselves before their next dialysis session. The facility did not have documented evidence of a hemodialysis agreement or policy and procedures, and initially claimed they had no residents receiving dialysis. Observations and interviews revealed that the resident's fistula access site was not monitored or the dressing removed by nursing staff as ordered. The resident stated that nursing staff rarely checked their fistula and never removed the dressing, leading them to do it themselves. On multiple occasions, the resident was seen with a dressing fully covering their left upper arm, indicating that the dressing had not been removed as per the physician's order. The Treatment Administration Record documented the dressing removal order, but it was not followed, and the resident was marked as out of the facility during the scheduled dressing removal time. Interviews with nursing staff and a regional registered nurse confirmed the oversight. The LPN responsible for the resident's care stated they monitored the access site but did not realize the dressing was still in place. The regional registered nurse emphasized the importance of removing the dressing as ordered to properly monitor the access site for complications and signs of infection. The failure to adhere to the physician's order and monitor the dialysis access site appropriately led to the deficiency identified during the survey.
Improper Labeling and Storage of Medications
Penalty
Summary
During a recertification survey, it was observed that the facility failed to ensure proper labeling and storage of drugs and biologicals in accordance with accepted professional principles. Specifically, on the South unit's medication cart #2, an insulin lispro pen for one resident, an insulin glargine pen for another resident, and an Anoro Ellipta inhaler for a third resident were found without opened or expiration dates. This lack of labeling could potentially compromise the effectiveness of the medications, as insulin is known to expire 28 days after opening, and the inhaler expires 6 weeks after being opened. Licensed Practical Nurse #31 acknowledged the oversight, stating that the nurse who opens the medication is responsible for dating it, and that insulin should be checked for expiration before administration. Registered Nurse Unit Manager #5 confirmed that cart audits are conducted monthly to check for expired medications and reiterated the importance of dating insulin pens. However, there was uncertainty regarding the need for dating inhalers, which was later clarified by a pharmacist who informed that the Anoro Ellipta inhaler expires 6 weeks after opening.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable, flavorful, and appetizing, as evidenced by the findings during the recertification survey. On two separate occasions, test trays revealed that food items were served at temperatures below the facility's standards. On the first occasion, beef stew was served at 114 degrees Fahrenheit and a green and yellow bean mix at 108 degrees Fahrenheit, both below the required 140 degrees Fahrenheit. On the second occasion, French-fried potatoes were found to be cold and undercooked, and other food items were also below the appropriate serving temperatures. Interviews and observations indicated that the facility's meal service policy, which required meals to be served promptly to maintain adequate temperature and appearance, was not adhered to. The Food Service Director acknowledged the temperature discrepancies and noted the absence of plate warmers as a contributing factor. Additionally, the facility failed to provide documentation of test trays when requested, indicating a lack of proper monitoring and record-keeping. A resident had previously complained about cold food, further highlighting the issue.
Failure to Provide Diet Consistent with Resident's Needs
Penalty
Summary
The facility failed to provide a diet in a form designed to meet the individual needs of a resident, specifically Resident #33, during a recertification survey. The resident, who had diagnoses including dementia, diabetes, and cervicalgia, was supposed to receive a controlled carbohydrate, mechanical soft texture diet with thin liquids as per the physician's order. However, during an observation, the resident was served a lunch tray that contained beef stew with chunks of beef larger than one inch, which was inconsistent with the mechanical soft diet requirement. The facility's menu extension sheets specified that the mechanical soft beef stew should be ground with no peas, but this was not followed. Interviews with staff revealed a lack of adherence to the facility's policy on modified food consistency. Certified Nurse Aide #15 admitted to not checking the tray and ticket for every resident, while the Supervisor #36 acknowledged that the beef stew prepared for the resident was intended for a regular diet, not a mechanical soft diet. The Food Service Director confirmed that kitchen staff were responsible for ensuring the correct consistency of meals, and the Speech Language Pathologist emphasized the importance of providing the correct food consistency to prevent complications such as aspiration, weight loss, and malnutrition.
Resident Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that Resident #35 had a means of directly contacting staff for assistance, as their call bell was consistently found to be out of reach. This deficiency was identified during a recertification survey conducted from May 6 to May 10, 2024. The facility's policy, revised in August 2019, emphasized the importance of timely response to call bells to ensure high-quality resident outcomes. Resident #35, who had moderately impaired cognition and was dependent on staff for various activities, was observed multiple times with their call bell on the floor and out of reach, despite their comprehensive care plan indicating the need for the call bell to be within reach to mitigate fall risks. Interviews with facility staff, including a certified nurse aide, a licensed practical nurse, and a registered nurse unit manager, confirmed that call bells should be within residents' reach to allow them to communicate their needs or potential emergencies. The staff acknowledged that Resident #35 was capable of using the call bell and that it was crucial for it to be accessible. The repeated observations of the call bell being out of reach highlighted a failure in adhering to the facility's policy and ensuring the resident's safety and ability to communicate needs.
Pest Control Deficiency in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in evidence of mice in a resident room. The third-party pest control vendor had previously treated the room for mice and rodents on multiple occasions earlier in the year. However, during the recertification survey, a resident reported recent sightings of mice in their room, including one that emerged from the heater and ran into the hall. The resident's roommate confirmed these sightings. Upon inspection, the Director of Housekeeping and Laundry found rodent droppings and chewed candy wrappers inside the heater unit in the resident's room. The heater had an open hole in its casing, allowing pests to enter and exit. The exterior of the heater was also observed to have metal slats with gaps, providing no barrier against pests. The Administrator acknowledged that both housekeeping and maintenance were responsible for pest management and emphasized the importance of keeping the facility free of pests to prevent disease spread.
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 173 citations issued within 25 miles in the last 12 months — including the 6 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 Minoa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunnyside Care Center | 2.9 mi | — | 14 | 0 |
| Jewish Home Of Central New York | 4.9 mi | — | 18 | 0 |
| Nottingham R H C F | 6.6 mi | — | 7 | 0 |
| The Grand Rehabilitation And Nrsg At Chittenango | 6.8 mi | — | 18 | 0 |
| Bishop Rehabilitation And Nursing Center | 7.2 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Onondaga Center For Rehabilitation And Nursing.
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 August 2026) and official state health department websites.