Inspection Reports for
Northwoods Rehabilitation and Nursing Center at Moravia
7 Keeler Avenue, Moravia, NY, 13118
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
17.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
247% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 18, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements, focusing on allegations of abuse, neglect, and medication errors involving residents.
Findings
The facility failed to thoroughly investigate allegations of neglect related to medication errors for two residents and did not report these incidents to the New York State Department of Health as required. Registered Nurse #16 falsely documented medication administration and failed to administer multiple doses of intravenous antibiotics, resulting in minimal harm or potential for actual harm to residents.
Deficiencies (2)
F 0610: The facility did not ensure allegations of abuse, neglect, or mistreatment were thoroughly investigated for two residents. Medication errors were not properly reported to the state as required.
F 0760: The facility failed to ensure residents were free from significant medication errors. Registered Nurse #16 falsely documented administering clonazepam and failed to administer multiple doses of intravenous antibiotics to two residents.
Report Facts
Residents affected: 2
Medication administration omissions: 6
Clonazepam tablets remaining: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #16 | Registered Nurse | Falsely documented medication administration and failed to administer multiple doses of intravenous antibiotics. |
| Director of Nursing #6 | Former Director of Nursing | Completed investigative narratives and disciplinary write-up related to medication errors. |
| Licensed Practical Nurse #22 | Licensed Practical Nurse | Documented resident return from hospital and infection status. |
| Physician #18 | Physician | Provided statements regarding expectations for antibiotic administration and notification. |
| Licensed Practical Nurse #11 | Licensed Practical Nurse | Provided interview statements about medication administration and reporting procedures. |
| Director of Nursing #2 | Director of Nursing | Provided interview statements about medication administration policies and investigations. |
| Administrator | Facility Administrator | Responsible for reporting abuse and neglect; acknowledged failure to report medication errors to the state. |
Inspection Report
Annual Inspection
Capacity: 40
Deficiencies: 7
Date: Nov 18, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements and investigate allegations of abuse, neglect, and medication errors.
Complaint Details
The visit was complaint-related due to allegations of abuse, neglect, and medication errors involving Residents #32 and #45. The facility failed to thoroughly investigate and report these incidents as required.
Findings
The facility failed to thoroughly investigate allegations of neglect related to medication errors and did not report incidents to the state. The activities program was not directed by a qualified professional. Residents did not consistently receive ordered treatments, nutritional supplements, or adequate nursing coverage. Medication errors, including falsification of medication administration and failure to administer intravenous antibiotics, were identified. Medication storage and labeling practices were deficient.
Deficiencies (7)
F 0610: The facility did not ensure allegations of abuse, neglect, or mistreatment were thoroughly investigated for two residents and failed to report medication errors to the state.
F 0680: The activities program was not directed by a qualified professional with required credentials and experience.
F 0684: Resident #5 did not receive wound treatment order changes, lacked weekly wound follow-up, and wounds were not fully included in the care plan.
F 0692: Resident #31 experienced significant weight loss and did not receive planned nutritional supplements or acceptable substitutions.
F 0727: The facility did not provide eight consecutive hours of Registered Nurse coverage seven days a week as required.
F 0760: Registered Nurse #16 falsely documented administering clonazepam and failed to administer multiple doses of intravenous antibiotics to residents.
F 0761: Medication carts and treatment cart were unlocked and unattended; medication room refrigerator was unclean with ice buildup; medications were not dated when opened and expired medications were present.
Report Facts
Licensed beds: 40
Average daily census: 35
Registered nurse coverage days missed: 7
Weight loss percentage: 6.7
Medication administration omissions: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #16 | Registered Nurse | Named in medication error findings for falsifying medication administration and failing to administer intravenous antibiotics. |
| Director of Nursing #2 | Director of Nursing | Interviewed regarding medication administration, wound care, and nursing coverage deficiencies. |
| Former Director of Nursing #6 | Former Director of Nursing | Provided investigative narratives and disciplinary documentation related to medication errors. |
| Physician #18 | Physician | Interviewed regarding expectations for notification of missed intravenous antibiotics. |
| Certified Nurse Aid #10 | Certified Nurse Aid | Interviewed about meal tray delivery and nutritional supplement issues. |
| Registered Dietitian #13 | Registered Dietitian | Monitored weight loss and nutritional supplement recommendations. |
| Director of Activities #9 | Director of Activities | Found not qualified to direct activities program. |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jun 13, 2024
Visit Reason
The inspection was a recertification and abbreviated survey conducted from June 10, 2024 through June 13, 2024 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in developing and implementing comprehensive care plans for residents, ensuring assistance with activities of daily living, posting nurse staffing information, proper medication labeling, serving food at safe temperatures, and maintaining food service area cleanliness.
Deficiencies (6)
F 0656: The facility failed to develop and implement comprehensive care plans with measurable objectives for 3 of 12 residents, including lack of care planning for contractures and anticoagulant therapy.
F 0677: The facility did not ensure residents unable to perform activities of daily living received necessary grooming assistance, specifically Resident #22 was not assisted with shaving unwanted facial hair.
F 0732: The facility failed to post daily nurse staffing information and resident census in a publicly accessible area for 4 of 4 days reviewed.
F 0761: The facility did not maintain proper labeling on medications; specifically, three opened medicated eye drops on a medication cart were undated.
F 0804: The facility served food that was not palatable or at safe and appetizing temperatures, with a lunch tray containing items below required temperature standards.
F 0812: The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards; floors under dish machine and walk-in cooler were unclean with food debris and liquid spills.
Report Facts
Residents reviewed for care planning: 12
Days of survey: 4
Medication carts reviewed: 2
Temperature of cheeseburger: 112
Temperature of carrots: 111
Temperature of milk: 55
Temperature of pudding: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #16 | Certified Nurse Aide | Interviewed regarding Resident #6's contracture care plan |
| Licensed Practical Nurse #9 | Licensed Practical Nurse | Interviewed regarding care plan development for Resident #6 |
| Registered Nurse #8 | Registered Nurse | Interviewed regarding nursing section of care plan development |
| Physical Therapist #14 | Physical Therapist | Interviewed regarding care planning for contracture management |
| Occupational Therapist #15 | Occupational Therapist | Interviewed regarding care planning and therapy for Resident #6 |
| Licensed Practical Nurse #12 | Licensed Practical Nurse | Interviewed regarding care plan knowledge and medication administration |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding care plan review and updates |
| Certified Nurse Aide #13 | Certified Nurse Aide | Interviewed regarding personal hygiene care for Resident #22 |
| Nurse Staff Scheduler/Charge Nurse #9 | Nurse Staff Scheduler/Charge Nurse | Interviewed regarding nurse staffing posting |
| Director of Nursing | Director of Nursing | Interviewed regarding medication labeling and staffing posting |
| Licensed Practical Nurse #12 | Licensed Practical Nurse | Interviewed regarding medication cart observations |
| Administrator | Administrator and Acting Food Service Director | Interviewed regarding food temperatures and kitchen cleanliness |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jun 13, 2024
Visit Reason
The survey was conducted as a recertification and abbreviated survey of the nursing home to assess compliance with regulatory requirements.
Findings
The facility failed to ensure that residents unable to perform activities of daily living received necessary grooming assistance, specifically shaving for one resident. Additionally, the facility did not ensure food and drink were served at palatable and safe temperatures during a meal test.
Deficiencies (2)
F 0677: The facility did not assist Resident #22 with shaving unwanted facial hair despite care plan instructions and resident requests. Staff failed to bring a razor or offer shaving assistance during the survey period.
F 0804: The facility served food and drink that were not palatable or at safe and appetizing temperatures during the 6/11/2024 lunch meal test tray. Hot foods measured below required temperatures.
Report Facts
Food temperature measurement: 112
Food temperature measurement: 111
Food temperature measurement: 55
Food temperature measurement: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #13 | Interviewed regarding personal hygiene care and shaving assistance for Resident #22 | |
| Licensed Practical Nurse #12 | Interviewed regarding certified nurse aide responsibilities and shaving care for Resident #22 | |
| Assistant Director of Nursing | Interviewed regarding personal hygiene care expectations and documentation for Resident #22 | |
| Administrator / Acting Food Service Director | Interviewed regarding food temperature policies and practices |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: Jun 13, 2024
Visit Reason
Complaint survey with multiple quality of care and life safety code deficiencies, all corrected.
Findings
Complaint survey with multiple quality of care and life safety code deficiencies, all corrected.
Deficiencies (15)
ADL care provided for dependent residents
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Label/store drugs and biologicals
Nutritive value/appear, palatable/prefer temp
Posted nurse staffing information
Cooking facilities
Discharge from exits
Fire alarm system - testing and maintenance
Fire drills
Hazardous areas - enclosure
Means of egress - general
Roles under a waiver declared by secretary
Sprinkler system - installation
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 7
Date: May 25, 2022
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 5/23/22 to 5/25/22 to assess compliance with federal and state regulations for nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to notify residents of Medicare coverage changes, inadequate assistance with activities of daily living such as shaving, failure to implement nutritional supplement recommendations, improper use and assessment of bed rails, serving food at unsafe temperatures, improper food storage and sanitation in the kitchen, and failure to inspect beds for entrapment risks.
Deficiencies (7)
F 0582: The facility failed to inform residents and/or their representatives of changes to Medicare coverage and potential financial liability for non-covered services for 2 of 3 residents reviewed.
F 0677: The facility failed to provide adequate assistance with shaving for 1 of 4 residents, who preferred more frequent shaving than provided.
F 0692: The facility failed to ensure nutritional recommendations by the registered dietitian to increase supplements were implemented for 1 of 2 residents with significant weight loss.
F 0700: The facility failed to assess, obtain consent, and document bed rail use and risks for 4 of 12 residents with bed rails in use.
F 0804: The facility failed to provide food and drink at safe and appetizing temperatures; lunch meal items were served below recommended temperatures and were unpalatable.
F 0812: The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards; kitchen floors and exhaust hood were unclean and raw chicken was improperly stored above cooked food.
F 0909: The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails to identify entrapment risks; Resident #24's bed rails failed entrapment testing due to bent rails.
Report Facts
Resident weight loss: 15
Temperature of BBQ rib: 104
Temperature of French fries: 103
Temperature of milk: 65
Date of survey completion: May 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nurse Aide | Interviewed regarding shaving assistance for Resident #2 |
| LPN Unit Manager #6 | Licensed Practical Nurse Unit Manager | Interviewed regarding nutritional supplement communication and bed rail assessments |
| RD #18 | Registered Dietitian | Provided nutritional supplement recommendations for Resident #35 |
| Director of Nursing | Director of Nursing | Interviewed regarding personal hygiene and bed rail policies |
| Food Service Director | Food Service Director | Interviewed regarding food temperatures and kitchen sanitation |
| Director of Environmental Services | Director of Environmental Services | Interviewed regarding bed rail inspections and kitchen sanitation |
| Physician #13 | Physician | Interviewed regarding bed rail orders and assessments |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 14
Date: May 25, 2022
Visit Reason
Complaint survey with multiple quality of care and life safety code deficiencies, all corrected.
Findings
Complaint survey with multiple quality of care and life safety code deficiencies, all corrected.
Deficiencies (14)
ADL care provided for dependent residents
Bedrails
Food procurement,store/prepare/serve-sanitary
Medicaid/medicare coverage/liability notice
Nutrition/hydration status maintenance
Nutritive value/appear, palatable/prefer temp
Resident bed
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Gas equipment - cylinder and container storag
Hazardous areas - enclosure
Sprinkler system - installation
Sprinkler system - maintenance and testing
Vertical openings - enclosure
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