Inspection Reports for
Morningstar Residential Care Center
17 Sunrise Drive, Oswego, NY, 13126
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Inspection Report — Aug 14, 2025
Complaint Investigation State
Date: Aug 14, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from 2023 to 2025 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 116 complaints about this facility; 10 led to on-site inspections. The facility received 108.9 complaints per 100 beds versus a statewide rate of 57.4. 13 citations resulted from those complaints.
Findings
Across 8 inspections, 52 citations were issued including 30 standard health and 22 life safety code citations. The facility had multiple deficiencies ranging from immediate jeopardy to minor potential harm, with 3 enforcement actions totaling $30,000 in fines.
Citations (51)
Standard Health Citation — quality of care: Request/refuse/discontinue Treatment; formulate Advance Directive not properly handled.
Standard Health Citation — quality of care: Treatment/services to prevent or heal pressure ulcers were deficient.
Standard Health Citation — quality of care: ADL care provided for dependent residents was inadequate.
Standard Health Citation — quality of care: Bedrails were not properly managed.
Standard Health Citation — quality of care: Criminal history record check process was deficient.
Standard Health Citation — quality of care: Dialysis care was deficient.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and serving were not sanitary.
Standard Health Citation — quality of care: Frequency of meals/snacks at bedtime was inadequate.
Standard Health Citation — quality of care: Infection control practices were deficient.
Standard Health Citation — quality of care: License compliance with federal, state, local law and professional standards was deficient.
Standard Health Citation — quality of care: Nutritive value, appearance, palatability, and preferred temperature of food were inadequate.
Standard Health Citation — quality of care: Resident allergies, preferences, and substitutes were not properly managed.
Standard Health Citation — quality of care: Resident rights and exercise of rights were deficient.
Standard Health Citation — quality of care: Respiratory/tracheostomy care and suctioning were deficient.
Standard Health Citation — quality of care: Safe, clean, comfortable, homelike environment was not maintained.
Life Safety Code Citation — NFPA requirements: Building construction type and height did not meet standards.
Life Safety Code Citation — NFPA requirements: Doors with self-closing devices were deficient.
Life Safety Code Citation — NFPA requirements: Electrical equipment power cords and extensions were deficient.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system were deficient.
Life Safety Code Citation — NFPA requirements: Emergency preparedness training program was deficient.
Life Safety Code Citation — NFPA requirements: Fire alarm system testing and maintenance were deficient.
Life Safety Code Citation — NFPA requirements: Gas equipment cylinder and container storage were deficient.
Life Safety Code Citation — NFPA requirements: Hazardous areas enclosure was deficient.
Life Safety Code Citation — NFPA requirements: HVAC system was deficient.
Life Safety Code Citation — NFPA requirements: Illumination of means of egress was deficient.
Life Safety Code Citation — NFPA requirements: Means of egress general conditions were deficient.
Life Safety Code Citation — NFPA requirements: Smoking regulations were deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler system installation was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing were deficient.
Life Safety Code Citation — NFPA requirements: Stairways and smokeproof enclosures were deficient.
Life Safety Code Citation — NFPA requirements: Subsistence needs for staff and patients were deficient.
Life Safety Code Citation — NFPA requirements: Utilities gas and electric were deficient.
Standard Health Citation — quality of care: Treatment/services to prevent or heal pressure ulcers were deficient.
Standard Health Citation — quality of care: Develop/implement comprehensive care plan was deficient.
Standard Health Citation — quality of care: Free of accident hazards/supervision/devices was deficient.
Standard Health Citation — quality of care: Cardio-pulmonary resuscitation (CPR) was deficient.
Standard Health Citation — quality of care: ADL care provided for dependent residents was inadequate.
Standard Health Citation — quality of care: Develop/implement comprehensive care plan was deficient.
Standard Health Citation — quality of care: Dialysis care was deficient.
Standard Health Citation — quality of care: Frequency of meals/snacks at bedtime was inadequate.
Standard Health Citation — quality of care: Increase/prevent decrease in range of motion/mobility was deficient.
Standard Health Citation — quality of care: Maintains effective pest control program was deficient.
Standard Health Citation — quality of care: Nutritive value, appearance, palatability, and preferred temperature of food were inadequate.
Standard Health Citation — quality of care: Quality of care was deficient.
Standard Health Citation — quality of care: Resident rights and exercise of rights were deficient.
Standard Health Citation — quality of care: Safe, clean, comfortable, homelike environment was not maintained.
Life Safety Code Citation — NFPA requirements: Cooking facilities were deficient.
Life Safety Code Citation — NFPA requirements: Discharge from exits was deficient.
Life Safety Code Citation — NFPA requirements: Electrical equipment testing and maintenance were deficient.
Life Safety Code Citation — NFPA requirements: Hazardous areas enclosure was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler system installation was deficient.
Report Facts
Inspections on page: 8
Total citations: 52
Standard Health citations: 30
Life Safety Code citations: 22
Total complaints: 116
On-site complaint inspections: 10
Complaint citations issued: 13
Enforcement actions: 3
Total fines: 30000
Inspection Report — Aug 14, 2025
Abbreviated Survey CMS
Date: Aug 14, 2025
Visit Reason
The abbreviated survey was conducted to investigate the facility's compliance with documenting and communicating residents' advance directives, specifically after an incident involving Resident #1 where cardiopulmonary resuscitation was not initiated per the resident's wishes.
Findings
The facility failed to consistently document and communicate Resident #1's advance directive status, resulting in failure to initiate cardiopulmonary resuscitation per the resident's wishes, causing actual harm and immediate jeopardy. The facility's verification process for medical orders related to advance directives was inadequate, placing all residents with advance directives at risk.
Citations (1)
F 0578: The facility failed to honor Resident #1's advance directive by not initiating cardiopulmonary resuscitation as documented on the Medical Orders for Life Sustaining Treatment form, resulting in the resident's death. The facility also failed to verify and communicate advance directive orders accurately, placing residents at risk.
Report Facts
Residents affected: 3
Residents affected: 104
Staff re-educated: 3
Mock Code Blue drills: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #9 | Entered incorrect Do Not Resuscitate/Do Not Intubate order without verification | |
| Licensed Practical Nurse #10 | Confirmed incorrect order without verification and acknowledged error | |
| Physician #6 | Physician | Signed advance directive order remotely without verifying accuracy |
| Licensed Practical Nurse #4 | Discovered resident without respirations and pulse, did not initiate CPR | |
| Nurse Practitioner #7 | Nurse Practitioner | Signed Medical Order for Life Sustaining Treatment form documenting Full Code status |
| Director of Nursing | Director of Nursing | Documented findings and was involved in facility investigation |
| Acting Administrator | Acting Administrator | Assisted with facility investigation and provided interviews |
Inspection Report — Aug 12, 2025
Abbreviated Survey CMS
Date: Aug 12, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with wound assessment and treatment standards, specifically focusing on pressure ulcer care for residents at risk.
Findings
The facility failed to ensure timely assessment, documentation, and treatment of a new pressure ulcer for one resident, resulting in delayed care. Corrective actions were implemented including re-education of staff, revised skin care protocols, and weekly skin checks, leading to regulatory compliance by the time of the survey.
Citations (1)
F 0686: The facility did not ensure residents with pressure ulcers received timely assessment and treatment. Resident #3 developed a new pressure ulcer that was not assessed or treated promptly, with no documentation or treatment orders for two weeks after discovery.
Report Facts
Residents Affected: 1
Length of untreated wound: 14
Wound dimensions: 2.5
Wound dimensions: 2.7
Wound dimensions: 0.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Failed to document resident's wound and obtain treatment order | |
| Registered Nurse Supervisor #4 | Failed to document resident's wound and obtain treatment order | |
| Certified Nurse Aide #1 | First to identify and report the resident's pressure ulcer | |
| Former Director of Nursing #5 | Conducted facility investigation and provided statements on wound care expectations | |
| Physician #7 | Provided expectations for wound assessment and treatment |
Inspection Report — May 2, 2025
Annual Inspection CMS
Date: May 2, 2025
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 4/28/2025 to 5/2/2025 to assess compliance with federal and state regulations for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect during feeding, safe and comfortable environment due to improper water temperatures, inadequate assistance with activities of daily living, improper respiratory care, lack of communication with dialysis providers, inappropriate use of bed rails, poor food quality and temperature, failure to accommodate resident food preferences, delayed meal service and lack of snacks, improper food storage and kitchen maintenance, and failure to provide required documentation timely to the state survey team.
Citations (11)
F 0550: Residents were not treated with dignity and respect during feeding; staff stood over residents, used inappropriate labels like feeders, and excluded residents from conversation.
F 0584: Water temperatures on Units A, B, and C were not maintained at comfortable levels between 2/4/2025 and 4/1/2025, causing discomfort to residents.
F 0677: Residents who were unable to perform activities of daily living did not consistently receive necessary assistance with toileting, oral hygiene, grooming, and shaving.
F 0695: Resident #88 did not receive oxygen therapy as ordered; portable oxygen tank was empty and care plan lacked oxygen therapy instructions.
F 0698: Resident #77 receiving hemodialysis lacked documented communication and collaboration with the dialysis facility; missing communication book and undocumented verbal reports.
F 0700: Resident #31 had enabler bars on bed despite physical therapy assessment contraindicating their use; no documented review of risks, benefits, or consent.
F 0804: Food served was not palatable, flavorful, or at safe appetizing temperatures; residents complained of bland, cold food and missing items.
F 0806: Residents #31 and #60 did not receive food accommodating their preferences; missing fruit, chips, and soda on meal trays despite care plan instructions.
F 0809: Suitable and nourishing alternative meals and snacks were not provided to residents who preferred to eat outside scheduled meal times; snacks were limited and meals were served late.
F 0812: Food was not stored, prepared, distributed, and served in accordance with professional standards; issues included unclean refrigerators, broken ice machine, leaking sink, and ice buildup on freezer door.
F 0836: Facility failed to provide required documentation including Facility Assessment, CMS-671, DOH-1550, DOH-2325, Equipment Inventory, Legionella policies, and list of recently hired employees within required timeframes.
Report Facts
Residents affected: 3
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 5
Residents affected: 2
Residents affected: 3
Employees list delay: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #4 | Named in dignity and respect feeding observations and interviews | |
| Certified Nurse Aide #5 | Named in dignity and respect feeding observations and oral hygiene care | |
| Certified Nurse Aide #16 | Named in dignity and respect feeding observations | |
| Certified Nurse Aide #18 | Named in dignity and respect feeding observations and food tray missing items | |
| Certified Nurse Aide #19 | Named in oral hygiene and food service observations | |
| Certified Nurse Aide #22 | Named in enabler bars and feeding observations | |
| Certified Nurse Aide #37 | Named in oral hygiene and shaving care | |
| Licensed Practical Nurse #20 | Named in feeding, oral hygiene, oxygen therapy, and food service interviews | |
| Licensed Practical Nurse #7 | Named in dialysis communication interview | |
| Licensed Practical Nurse #23 | Resident Care Coordinator | Named in oxygen therapy care plan interview |
| Licensed Practical Nurse #41 | Named in dialysis communication interview | |
| Registered Dietitian #3 | Named in feeding, food preference, and snack availability interviews | |
| Physical Therapist #31 | Named in enabler bars assessment | |
| Director of Nursing | Named in multiple interviews regarding feeding, oxygen therapy, enabler bars, and food service | |
| District Food Services Manager #36 | Named in food service operations and snack availability interviews | |
| Maintenance Worker #32 | Named in ice machine and maintenance interviews | |
| Director of Maintenance/Laundry/Housekeeping #15 | Named in kitchen cleaning and maintenance interviews |
Inspection Report — Jan 7, 2025
Abbreviated Survey CMS
Date: Jan 7, 2025
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with professional standards of care related to pressure ulcer treatment and prevention for residents at risk or with existing pressure ulcers.
Findings
The facility failed to ensure residents with pressure ulcers or at risk received timely and appropriate treatment, including wound care orders, diagnostic testing, and nutritional reassessment. There were delays and omissions in updating treatment orders, obtaining recommended labs and x-rays, and notifying the registered dietitian after significant weight loss and new pressure ulcers developed.
Citations (1)
F 0686: The facility did not provide appropriate pressure ulcer care and failed to prevent new ulcers from developing for 2 of 3 residents reviewed. Treatment orders and diagnostic tests were not obtained or implemented timely, and nutritional reassessment was not done after significant weight loss.
Report Facts
Weight loss percentage: 5.4
Antibiotic dosage: 100
Pressure ulcer stages: 3
Pressure ulcer stages: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Manager #4 | Licensed Practical Nurse Manager | Responsible for reviewing consultant recommendations and entering orders into the resident's electronic record. |
| Wound Physician #2 | Wound Physician | Provided wound care recommendations and treatment plans for residents' pressure ulcers. |
| Registered Dietitian #9 | Registered Dietitian | Conducted nutritional assessments and documented dietary interventions for residents. |
| Director of Nursing | Director of Nursing | Provided information about nursing responsibilities related to weight monitoring and notification of dietitian. |
Inspection Report — Sep 3, 2024
Abbreviated Survey CMS
Date: Sep 3, 2024
Visit Reason
The abbreviated survey was conducted to assess compliance with care planning and supervision requirements, specifically addressing concerns about a resident exhibiting exit-seeking behaviors and wandering.
Findings
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with exit-seeking behaviors and did not provide adequate supervision to prevent the resident from leaving the building unsupervised. The resident exited the building and was found in the parking lot without injury.
Citations (2)
F 0656: The facility did not develop and implement a complete care plan addressing a resident's exit-seeking behaviors, resulting in the resident exiting the building unsupervised.
F 0689: The facility failed to ensure adequate supervision to prevent accidents, allowing a resident with frequent exit-seeking behaviors to leave the building and be found in the parking lot.
Report Facts
Incident time: 355
Wandering risk score: 6
Fall dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Supervisor #1 | Licensed Practical Nurse Supervisor | Completed incident report and responded to resident exit |
| Certified Nurse Aide #2 | Certified Nurse Aide | Reported resident exit and described exit-seeking behaviors |
| Licensed Practical Nurse #18 | Licensed Practical Nurse | Described resident wandering and exit-seeking behaviors |
| Activities Director | Activities Director | Reported resident exit-seeking behaviors and staff redirection efforts |
| Licensed Practical Nurse Unit Manager #17 | Licensed Practical Nurse Unit Manager | Responsible for care plans and described lack of care plan for wandering |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Floor nurse and shift supervisor during resident exit incident |
Inspection Report — Mar 4, 2024
Abbreviated Survey CMS
Date: Mar 4, 2024
Visit Reason
The abbreviated survey was conducted due to a failure to administer cardiopulmonary resuscitation (CPR) to a resident who wished to be resuscitated, raising concerns about compliance with residents' advance directives and life support policies.
Findings
The facility failed to initiate CPR for Resident #1 who was found without a pulse and respirations despite having a documented Full Code order. Staff followed the spouse's request not to initiate CPR, although the spouse was not the resident's decision maker, resulting in immediate jeopardy to resident health and safety.
Citations (1)
F 0678: The facility failed to provide basic life support, including CPR, prior to emergency medical personnel arrival, contrary to the resident's advance directives. Staff did not initiate CPR for Resident #1 who wished resuscitation, placing all 108 residents with advance directives at risk.
Report Facts
Residents affected: 108
Residents affected: 1
Inspection Report — Aug 18, 2023
Annual Inspection CMS
Date: Aug 18, 2023
Visit Reason
The inspection was a recertification survey conducted from 8/10/2023 to 8/18/2023 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, safe and homelike environment, comprehensive care planning, activities of daily living assistance, treatment and care according to orders, range of motion care, dialysis care, food service quality and timeliness, and pest control. Several residents were observed not receiving care as planned, meals were served late and at improper temperatures, and pest control was inadequate with fruit flies observed in multiple areas.
Citations (10)
F 0550: Residents were not treated with dignity and respect; Resident #103's urinary catheter bag was uncovered and visible, and Resident #108 had facial hair left unremoved despite preferences.
F 0584: The facility did not ensure a safe, clean, comfortable, and homelike environment; damaged walls, floors, peeling paint, and black substance were observed in resident units B and C.
F 0656: Resident #101 with suicide risk had hazardous items in room and inconsistent 15-minute safety checks documented.
F 0677: Residents #38, 51, 69, 75, and 105 did not consistently receive assistance with activities of daily living including ambulation, toileting, oral care, grooming, and positioning as planned.
F 0684: Resident #38 was treated with unlabeled antifungal powder applied by unlicensed staff without physician order or proper documentation.
F 0688: Resident #7 with limited range of motion was not wearing prescribed right hand splint/brace as planned, and staff were unaware of the splint requirement.
F 0698: Resident #63 receiving hemodialysis lacked documented monitoring and plans for dialysis access sites; orders were incomplete and monitoring was not documented.
F 0804: Food was not served at palatable and safe temperatures during multiple meals; hot foods were below 135°F and cold foods above 41°F, and meals were served late.
F 0809: Meals and snacks were served late, with resident meal trays served up to 2 hours and 29 minutes after scheduled mealtimes on units A, B, and C.
F 0925: Facility did not maintain an effective pest control program; fruit flies were observed on resident units A, B, C, physical therapy space, and main kitchen.
Report Facts
Deficiencies cited: 10
Resident affected count: 5
Fruit flies count: 25
Meal service delay: 149
Dialysis frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse Resident Care Coordinator | Named in care plan and safety check deficiencies for Resident #101 and Resident #75. |
| CNA #9 | Certified Nurse Aide | Observed applying antifungal powder and involved in care of Resident #38. |
| LPN #6 | Licensed Practical Nurse | Interviewed regarding dignity, catheter care, and pest control observations. |
| OT #12 | Occupational Therapist | Provided therapy and care plan recommendations for Resident #7. |
| DON | Director of Nursing | Interviewed regarding care plan oversight and treatment deficiencies. |
| District Food Service Manager | Food Service Manager | Interviewed regarding food temperature and meal service deficiencies. |
Inspection Report — May 24, 2021
Annual Inspection CMS
Date: May 24, 2021
Visit Reason
The inspection was a recertification survey and abbreviated survey to assess compliance with regulatory standards for the nursing home.
Findings
The facility was found deficient in multiple areas including failure to promptly resolve resident grievances, inadequate assessment and treatment after a resident fall, insufficient range of motion interventions for a resident with contractures, food service safety violations including unclean cooler and dry storage areas, lack of proper medical decision-making capacity assessments before implementing advance directives, and ineffective pest control with fruit flies observed in the kitchen.
Citations (6)
F 0585: The facility did not make prompt efforts to resolve a resident's grievance regarding a missing shirt, and no missing property report was initiated.
F 0684: Resident was not assessed timely by a qualified professional after a fall and pain complaint, resulting in delayed hospital transfer for a fractured femur.
F 0688: Resident with limited range of motion was observed without recommended towel positioning and did not receive documented range of motion interventions.
F 0812: The walk-in cooler floor was soiled with dark liquid and broken eggs, and the dry storage room floor was sticky with food debris, indicating poor food service sanitation.
F 0836: Two residents had advance directives implemented without documented assessment of their medical decision-making capacity as required by state law.
F 0925: Fruit flies were observed in the main kitchen, and pest control records did not document identification or treatment of this pest issue.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 2
Fruit flies observed: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in fall incident and MOLST witnessing |
| LPN #6 | Licensed Practical Nurse | Named in fall incident and resident assessment |
| Director of Nursing | Director of Nursing | Interviewed regarding fall assessment procedures |
| Director of Social Services | Director of Social Services | Interviewed regarding grievance and MOLST processes |
| Food Service Director | Food Service Director | Interviewed regarding kitchen sanitation and pest control |
| Physical Therapist #3 | Physical Therapist | Interviewed regarding range of motion care |
| Registered Nurse MDS Coordinator #24 | Registered Nurse | Interviewed regarding resident care and positioning |
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