Inspection Reports for
Onondaga Center for Rehabilitation and Nursing
217 East Avenue, Minoa, NY, 13116
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
32
24
16
8
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 20, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory standards for the nursing home.
Findings
The facility failed to ensure appropriate treatment and care following a resident fall, adequate supervision to prevent accidents, and adherence to aspiration precautions and fall interventions for residents. Deficiencies involved failure to assess a resident after a fall, inadequate meal assistance for a resident on aspiration precautions, and insufficient fall prevention measures including call light accessibility and fall mat placement.
Deficiencies (2)
F 0684: The facility did not ensure Resident #85 was assessed by a qualified professional after an unwitnessed fall, violating the Falls Management and Prevention policy.
F 0689: The facility failed to provide adequate supervision to prevent accidents for Residents #70 and #80, including failure to follow aspiration precautions and fall prevention interventions.
Report Facts
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #21 | Documented Resident #85 fall and progress notes | |
| Certified Nurse Aide #30 | Assigned to Resident #85 and provided fall incident documentation | |
| Certified Nurse Aide #42 | Reported Resident #85 fall incident | |
| Licensed Practical Nurse #9 | Documented hearing about Resident #85 fall and interviewed regarding incident | |
| Assistant Director of Nursing #22 | Assistant Director of Nursing | Interviewed about fall assessment procedures |
| Director of Nursing | Director of Nursing | Interviewed about telehealth assessment process |
| Registered Nurse #24 | Documented speech therapy referral and interviewed about fall interventions | |
| Occupational Therapist #31 | Occupational Therapist | Provided discharge summary for Resident #70 |
| Speech Language Therapist #25 | Speech Language Therapist | Provided speech therapy evaluation and progress reports for Resident #70 |
| Licensed Practical Nurse #33 | Interviewed about meal assistance for Resident #70 | |
| Certified Nurse Aide #32 | Interviewed about meal assistance and straw use for Resident #70 | |
| Regional Director of Therapy | Regional Director of Therapy | Interviewed about level of assistance required at meals |
| Certified Nurse Aide #28 | Interviewed about fall precautions and call light placement for Resident #80 |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Nov 20, 2025
Visit Reason
The survey was a recertification and extended survey conducted to assess compliance with federal and state regulations for nursing home operations, resident care, and safety.
Findings
The facility was found deficient in multiple areas including failure to inform residents of their rights, failure to provide required Medicare non-coverage notices, failure to timely report incidents, inadequate cardiopulmonary resuscitation (CPR) training and failure to initiate CPR per resident wishes, failure to assess residents after falls, inadequate supervision to prevent accidents, lack of nursing staff competencies, failure to promptly notify providers of abnormal lab results, improper food storage and sanitation, and failure to maintain an effective infection prevention and control program.
Deficiencies (12)
F0575: The facility failed to ensure residents were informed of their rights and where to find complaint and advocacy information, which was posted in small print and at inaccessible heights.
F0582: The facility did not provide required Notice of Medicare Non-Coverage to two residents discharged from Medicare Part A services.
F0609: The facility failed to timely report suspected abuse and neglect to the State Survey Agency for one resident's death.
F0659: The facility failed to ensure staff with current CPR certification were present 24/7 and did not maintain hands-on CPR competencies for licensed nurses.
F0678: The facility failed to initiate CPR for a resident with a full code order who was found unresponsive and without a pulse, resulting in immediate jeopardy.
F0684: The facility failed to assess a resident after an unwitnessed fall by a qualified professional and did not utilize telehealth for assessment when no registered nurse was on site.
F0689: The facility failed to provide adequate supervision to prevent accidents for two residents, including failure to assist a resident on aspiration precautions during meals and failure to maintain fall precautions and call light accessibility.
F0726: The facility failed to ensure licensed nurses had appropriate competencies and skill sets, including infection control and CPR, and failed to provide documented annual education and competencies for licensed nurses.
F0773: The facility failed to promptly notify ordering physicians of critical and abnormal laboratory results for three residents, resulting in immediate jeopardy.
F0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including improper cooling of food, food stored on the floor, undated food items, unclean kitchen equipment, and unclean dining room floors.
F0835: The facility failed to administer operations effectively and efficiently, contributing to deficiencies in CPR, laboratory notifications, and nursing staff competencies.
F0880: The facility failed to maintain an effective infection prevention and control program, including uncovered urinary catheter bags resting on the floor, lack of appropriate signage, and failure of staff to wear required personal protective equipment when providing care to residents on enhanced barrier precautions.
Report Facts
Residents affected: 8
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Licensed nurses reviewed: 5
Residents affected: 3
Staff educated: 21
Staff educated: 4
Average daily census: 75
Food temperature: 44
Urine volume: 1400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 7 | Licensed Practical Nurse | Found Resident #85 deceased and did not initiate CPR |
| Licensed Practical Nurse 29 | Licensed Practical Nurse | Disconnected feeding tube without gown and improper infection control |
| Certified Nurse Aide 28 | Certified Nurse Aide | Did not wear PPE when providing care to resident on enhanced barrier precautions |
| Assistant Director of Nursing | Assistant Director of Nursing | Responsible for nursing education and tracking CPR competencies |
| Director of Nursing | Director of Nursing | Oversight of nursing services and education |
| Administrator | Administrator | Responsible for overall facility administration and compliance |
| Nurse Practitioner 11 | Nurse Practitioner | Responsible for reviewing lab results |
| Physician 4 | Physician | Medical Director, expected to be notified of abnormal labs and CPR initiation |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
One Level 3 deficiency for free from abuse and neglect with actual harm; isolated scope; no severe systemic quality of care issues indicated.
Findings
One Level 3 deficiency for free from abuse and neglect with actual harm; isolated scope; no severe systemic quality of care issues indicated.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
The abbreviated survey was conducted due to concerns related to abuse of a resident by a staff member.
Complaint Details
The investigation was initiated following a complaint and reports from staff and residents about the abuse incident. The abuse was substantiated, and law enforcement was involved.
Findings
The facility failed to protect Resident #1 from physical abuse by a Licensed Practical Nurse who pushed the resident into a wall causing a nosebleed and fractured nasal bone. The nurse was suspended, arrested, and terminated. The facility conducted a comprehensive investigation and implemented staff education on abuse prevention.
Deficiencies (1)
F 0600: The facility failed to protect Resident #1 from physical abuse when a Licensed Practical Nurse pushed the resident into a wall causing a nosebleed and fractured nasal bone. The nurse was suspended and arrested.
Report Facts
Residents interviewed: 19
Staff educated: 12
Staff educated: 13
Residents monitored: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in physical abuse incident against Resident #1; suspended, arrested, and terminated. |
| Certified Nurse Aide #2 | Certified Nurse Aide | Witnessed and reported the abuse incident involving Resident #1 and Licensed Practical Nurse #1. |
| Director of Nursing | Director of Nursing | Received abuse report, initiated investigation, suspended Licensed Practical Nurse #1, and coordinated response. |
| Administrator | Administrator | Responded immediately to abuse report, conducted investigation, and oversaw corrective actions. |
| Registered Nurse Supervisor #4 | Registered Nurse Supervisor | Conducted assessment of Resident #1 post-incident and assisted in investigation. |
| Physician Assistant #8 | Physician Assistant | Ordered x-ray and follow-up evaluation for Resident #1 after abuse incident. |
| Social Worker #5 | Social Worker | Monitored Resident #1 post-incident and interviewed residents regarding abuse concerns. |
| Medical Director | Medical Director | Evaluated Resident #1 post-incident and confirmed nasal fracture. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: May 10, 2024
Visit Reason
Recertification and abbreviated surveys conducted from 5/6/2024 to 5/10/2024 to assess compliance with regulatory requirements for nursing home care and environment.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, safe and homelike environment, activities of daily living care, treatment and care according to orders, adequate supervision to prevent accidents, nutritional status maintenance, meal service timeliness, and infection prevention and control. Additionally, the facility lacked a water management plan to reduce Legionella risk.
Deficiencies (8)
F 0550: Residents were not treated with respect and dignity; staff had verbal confrontations in front of residents, failed to assist residents properly during meals, transported residents in wheelchairs backwards, and entered rooms without announcing themselves.
F 0584: The facility did not maintain a safe, clean, comfortable, and homelike environment; used briefs were found on floors and furniture, broken door handles and sliding door restrictors were not maintained, exposed wiring and broken tables were observed, and residents received cold beverages in disposable cups.
F 0677: Residents who were unable to carry out activities of daily living did not consistently receive necessary assistance with dressing, bathing, meal supervision, and grooming.
F 0684: Resident #60 with chronic kidney disease stage 5 did not have documented evidence of scheduled or completed nephrology follow-up appointments despite multiple attempts to schedule and resident complaints.
F 0689: Resident #379's bed was not maintained in the low position and call bell was out of reach; Resident #42 wandered unsupervised into other residents' rooms without appropriate monitoring or interventions.
F 0692: Resident #75 was not weighed as ordered, did not receive fortified pudding, and was not assisted with meals as care planned; nutritional needs were not reassessed since admission.
F 0809: Resident meal trays were delivered up to 1 hour and 25 minutes late on two nursing units, impacting timely meal service.
F 0880: Infection prevention and control program deficiencies included staff not wearing required personal protective equipment for residents on transmission-based precautions, inconsistent signage, and lack of a water management plan to reduce Legionella risk.
Report Facts
Residents reviewed: 11
Residents reviewed: 10
Residents reviewed: 5
Residents reviewed: 9
Samples collected: 14
Weight loss: 2.9
Weight loss percentage: 2.66
Meal delivery delay: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #8 | Certified Nurse Aide | Stood over Resident #36 while feeding, noted in dignity finding |
| Certified Nurse Aide #9 | Certified Nurse Aide | Transported Resident #59 backwards in wheelchair, noted in dignity finding |
| Certified Nurse Aide #10 | Certified Nurse Aide | Entered Resident #379's room without announcing, noted in dignity finding |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Provided expectations on feeding and resident care, noted in dignity and ADL findings |
| Registered Nurse Unit Manager #5 | Registered Nurse Unit Manager | Provided statements on feeding, resident care, and supervision, noted in multiple findings |
| Director of Nursing | Director of Nursing | Provided statements on resident care, supervision, and infection control |
| Certified Nurse Aide #37 | Certified Nurse Aide | Failed to wear gown and proper PPE for Resident #36 on enhanced barrier precautions |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed not wearing proper PPE for Resident #45 on droplet precautions |
| Registered Dietitian #14 | Registered Dietitian | Provided nutritional assessments and progress notes for Resident #75 |
| Certified Nurse Aide #15 | Certified Nurse Aide | Observed meal tray removal and provided statements on weights and meal assistance |
Inspection Report
Annual Inspection
Deficiencies: 18
Date: May 10, 2024
Visit Reason
The survey was a recertification and abbreviated survey conducted to assess compliance with regulatory requirements for nursing home care and operations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, medication self-administration, safe and homelike environment, comprehensive care planning, activities provision, nutrition and hydration, dialysis care, infection prevention and control, food safety, equipment maintenance, call system accessibility, and pest control.
Deficiencies (18)
F 0550: The facility failed to ensure residents were treated with respect and dignity, including inappropriate staff behavior and failure to remove disruptive residents timely.
F 0554: The facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate and lacked documented assessment for self-administration.
F 0584: The facility did not maintain a safe, clean, comfortable, and homelike environment, including used briefs left in resident rooms, broken fixtures, and cold beverages served in disposable cups.
F 0656: The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a language barrier and potential for victimization.
F 0677: The facility did not ensure residents unable to carry out activities of daily living received necessary assistance with nutrition, grooming, and hygiene.
F 0679: The facility did not provide ongoing programs to support residents' interests and physical, mental, and psychosocial well-being, with residents not offered meaningful activities as care planned.
F 0684: The facility failed to provide treatment and care consistent with professional standards for a resident requiring nephrology follow-up, with no documented evidence of scheduled or completed follow-up.
F 0692: The facility did not ensure residents maintained acceptable nutritional status, with a resident not weighed as ordered, not receiving fortified pudding, and not assisted with meals as care planned.
F 0698: The facility did not ensure a resident who required dialysis received services consistent with professional standards, including failure to remove dialysis access site dressing as ordered.
F 0761: The facility did not ensure drugs and biologicals were labeled and stored in accordance with professional principles, including insulin and inhalers not dated with opened or expiration dates.
F 0804: The facility did not ensure food and drink were palatable, flavorful, and served at safe temperatures, with beef stew and bean mix served below safe temperatures and cold, undercooked French fries.
F 0805: The facility did not ensure residents received diets in forms consistent with physician orders, including a resident receiving regular beef stew instead of mechanical soft.
F 0809: The facility did not ensure residents received meals at regular times comparable to normal mealtimes, with meal trays delivered up to 1 hour and 25 minutes late.
F 0812: The facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards, with kitchen equipment in disrepair, unclean surfaces, and leaks.
F 0880: The facility failed to provide and implement an infection prevention and control program, including failure to maintain transmission-based precautions and lack of a water management plan for Legionella.
F 0908: The facility did not maintain equipment in safe operating condition, with unit kitchenette refrigerators not maintaining proper temperatures.
F 0919: The facility did not ensure residents had a means of directly contacting staff for assistance, with a resident's call bell out of reach and inaccessible.
F 0925: The facility did not maintain an effective pest control program, with evidence of mice in a resident's room and rodent droppings in the heater unit.
Report Facts
Deficiencies cited: 17
Resident count reviewed: 11
Resident count reviewed: 10
Resident count reviewed: 5
Resident count reviewed: 2
Resident count reviewed: 2
Resident count reviewed: 1
Resident count reviewed: 1
Resident count reviewed: 1
Resident count reviewed: 1
Temperature: 114
Temperature: 108
Temperature: 128
Temperature: 118
Temperature: 58
Temperature: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #8 | Named in feeding assistance and supervision deficiency | |
| Certified Nurse Aide #9 | Named in resident supervision and behavior management | |
| Certified Nurse Aide #10 | Named in dignity and respect and feeding assistance | |
| Licensed Practical Nurse #2 | Named in medication and dialysis care deficiencies | |
| Registered Nurse Unit Manager #5 | Named in multiple care planning and supervision deficiencies | |
| Activities Director #29 | Named in activities provision deficiency | |
| Certified Nurse Aide #15 | Named in hygiene and nutrition deficiencies | |
| Registered Dietitian #14 | Named in nutrition and diet consistency deficiencies | |
| Licensed Practical Nurse #31 | Named in medication storage deficiency | |
| Regional Registered Nurse #1 | Named in infection control and dialysis care deficiencies | |
| Director of Housekeeping and Laundry | Named in pest control and kitchen maintenance deficiencies | |
| Food Service Director | Named in food temperature and kitchen maintenance deficiencies |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Dec 8, 2023
Visit Reason
Multiple deficiencies including Level 3 quality of care with actual harm, and Level 2 deficiencies for respiratory care and professional standards; all corrected by January 21, 2024.
Findings
Multiple deficiencies including Level 3 quality of care with actual harm, and Level 2 deficiencies for respiratory care and professional standards; all corrected by January 21, 2024.
Deficiencies (3)
Quality of care
Respiratory/tracheostomy care and suctioning
Services provided meet professional standards
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Dec 8, 2023
Visit Reason
The abbreviated survey was conducted to evaluate compliance with professional standards of quality and care for residents, including review of specific complaints and concerns related to treatment and care.
Findings
The facility failed to ensure timely and appropriate care for multiple residents, including failure to implement physician orders, inadequate monitoring and follow-up of critical conditions, and failure to clarify and manage respiratory care equipment. These deficiencies resulted in actual harm to several residents.
Deficiencies (3)
F 0658: The facility did not timely implement a physician's order to apply a condom catheter for Resident #8 due to supply issues, resulting in the resident going 16 days without the ordered device.
F 0684: The facility failed to provide appropriate treatment and monitoring for Residents #7, #9, and #10, resulting in actual harm including delayed assessment of worsening subdural hematoma, lack of wound care and follow-up, and failure to notify medical providers of condition changes.
F 0695: The facility did not ensure Resident #1 received appropriate respiratory care; the continuous positive airway pressure machine was removed by family without medical evaluation, and the facility failed to clarify hospital discharge instructions or obtain physician orders.
Report Facts
Residents reviewed: 4
Residents reviewed: 3
Days without condom catheter: 16
Surgical wound measurements: 18
Surgical wound measurements: 14
Sutures: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed practical nurse #28 | Licensed Practical Nurse | Noted inability to apply condom catheter due to supply issues |
| licensed practical nurse #29 | Licensed Practical Nurse | Reported supply issues and delays in condom catheter application |
| licensed practical nurse #19 | Licensed Practical Nurse | Did not document reasons for missed catheter application and involved in Resident #7 assessment |
| licensed practical nurse Manager #6 | Licensed Practical Nurse Manager | Described process for medication/treatment orders and supply issues |
| Central Supply Staff #31 | Central Supply Staff | Responsible for ordering supplies including condom catheters |
| registered nurse Manager #18 | Registered Nurse Manager | Involved in Resident #7 assessment and monitoring |
| physician's assistant #12 | Physician's Assistant | Provided medical evaluations and noted lack of orders for wound follow-up and respiratory care |
| licensed practical nurse Manager #33 | Registered Nurse Manager | Responsible for entering orders and scheduling outside consultant appointments |
| licensed practical nurse #5 | Licensed Practical Nurse | Reported communication about wound care and consultant referrals |
| licensed practical nurse #30 | Registered Nurse | Performed admission assessment and skin assessment for Resident #10 |
| emergency room physician #32 | Emergency Room Physician | Evaluated Resident #9 for severe wound infection and surgical intervention |
| licensed practical nurse Manager #6 | Licensed Practical Nurse Manager | Discussed Resident #1 respiratory care and family removal of CPAP machine |
| Regional registered nurse #7 | Regional Registered Nurse | Became aware of Resident #1's CPAP machine issue and lack of clarification |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Aug 1, 2023
Visit Reason
Level 2 deficiencies for bowel/bladder incontinence, investigation of alleged violations, and quality of care; all corrected by September 5, 2023.
Findings
Level 2 deficiencies for bowel/bladder incontinence, investigation of alleged violations, and quality of care; all corrected by September 5, 2023.
Deficiencies (3)
Bowel/bladder incontinence, catheter, uti
Investigate/prevent/correct alleged violation
Quality of care
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Aug 1, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to assess compliance with regulatory requirements related to medication management, treatment and care, and catheter use.
Findings
The facility failed to thoroughly investigate missing controlled substances for one resident, did not ensure timely notification of abnormal lab results for another resident, and did not assess the need for continued use of an indwelling catheter for a third resident.
Deficiencies (3)
F 0610: The facility did not ensure all alleged violations were thoroughly investigated for one resident with missing controlled substances. Staff were not fully re-educated and the incident was not reported to the state as required.
F 0684: The facility did not ensure a resident received treatment and care according to professional standards as abnormal lab values were not documented as notified to the medical provider.
F 0690: The facility did not assess a resident with an indwelling urinary catheter for removal as soon as possible and did not arrange a urology consultation as recommended.
Report Facts
Residents reviewed: 19
Residents reviewed: 7
Residents reviewed: 3
Missing Modafinil pills: 2
Lab WBC count: 14.4
Lab Sodium level: 152
Lab BUN level: 46
Lab Creatinine level: 1.81
Lab Digoxin level: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #13 | Licensed Practical Nurse | Named in controlled substances count and investigation |
| LPN #19 | Licensed Practical Nurse | Named in controlled substances count and investigation |
| LPN #10 | Licensed Practical Nurse | Named in controlled substances count and investigation |
| LPN #18 | Licensed Practical Nurse | Named in controlled substances count and investigation |
| LPN #20 | Licensed Practical Nurse | Named in controlled substances count and investigation |
| RN Manager #5 | Registered Nurse Manager | Named in abnormal lab notification and catheter care findings |
| PA #6 | Physician Assistant | Named in abnormal lab notification and catheter care findings |
| Physician #7 | Physician | Named in catheter care findings |
| Director of Nursing | Director of Nursing | Named in controlled substances investigation and care findings |
Inspection Report
Deficiencies: 0
Date: May 8, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Onondaga Center for Rehabilitation and Nursing, related to a regulatory survey completed on May 8, 2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Apr 18, 2022
Visit Reason
Multiple Level 2 deficiencies related to investigation, transfer/discharge, pressure ulcer treatment, all corrected by mid-2022.
Findings
Multiple Level 2 deficiencies related to investigation, transfer/discharge, pressure ulcer treatment, all corrected by mid-2022.
Deficiencies (3)
Investigate/prevent/correct alleged violation
Transfer and discharge requirements
Treatment/svcs to prevent/heal pressure ulcer
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 17
Date: Mar 14, 2022
Visit Reason
Multiple Level 2 deficiencies including ADL care, food sanitation, meal frequency, menus, nutrition, resident rights, medication errors, and pressure ulcer treatment; also Life Safety Code deficiencies including electrical equipment, systems, training, illumination, tracking, smoking regulations, and sprinkler system; all corrected by May-June 2022.
Findings
Multiple Level 2 deficiencies including ADL care, food sanitation, meal frequency, menus, nutrition, resident rights, medication errors, and pressure ulcer treatment; also Life Safety Code deficiencies including electrical equipment, systems, training, illumination, tracking, smoking regulations, and sprinkler system; all corrected by May-June 2022.
Deficiencies (17)
ADL care provided for dependent residents
Food procurement,store/prepare/serve-sanitary
Frequency of meals/snacks at bedtime
Menus meet resident nds/prep in adv/followed
Nutrition/hydration status maintenance
Nutritive value/appear, palatable/prefer temp
Provided diet meets needs of each resident
Resident rights/exercise of rights
Residents are free of significant med errors
Treatment/svcs to prevent/heal pressure ulcer
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Ep training program
Illumination of means of egress
Procedures for tracking of staff and patients
Smoking regulations
Sprinkler system - installation
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Mar 14, 2022
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory requirements for nursing home care and services.
Findings
The facility was found deficient in multiple areas including resident dignity during meal service, inadequate assistance with activities of daily living, pressure ulcer care, nutritional assessments, medication administration errors, food service quality and safety, and food storage and handling practices.
Deficiencies (10)
F 0550: The facility failed to ensure residents were treated with dignity and respect, as residents received meals on disposable plastic dishes during a short-staffed lunch meal on 3/6/22.
F 0677: The facility failed to provide necessary assistance with activities of daily living for 4 residents, including missed showers, delayed call bell responses, and missed therapy.
F 0686: The facility failed to provide appropriate pressure ulcer care for a resident with unstageable pressure ulcers, including inconsistent use of heel protection boots.
F 0692: The facility failed to ensure timely nutritional assessments and weight monitoring for a resident with a pressure ulcer, resulting in inadequate nutritional status monitoring.
F 0760: The facility failed to prevent a significant medication error when a resident was administered only 500 mg of Metformin instead of the ordered 1000 mg dose.
F 0800: The facility failed to provide a nourishing, palatable, well-balanced diet meeting residents' nutritional and dietary needs, including failure to provide a requested soft salad sandwich.
F 0803: The facility failed to follow preplanned menus, resulting in multiple menu substitutions without resident notification, inadequate portion sizes, and use of unapproved food items.
F 0804: The facility failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures, including serving watered-down cranberry juice, bland chicken salad, cold French fries, and unattractive soup.
F 0809: The facility failed to provide suitable, nourishing alternative meals and snacks to residents who wanted to eat outside scheduled meal times, with nursing units lacking stocked snack items.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including use of a mechanical dishwasher that did not adequately sanitize dishes, expired milk stored in the cooler, and improper hot holding of hot dogs, mashed potatoes, and soup.
Report Facts
Residents reviewed: 78
Residents affected: 72
Residents reviewed: 11
Residents affected: 4
Residents reviewed: 4
Residents affected: 1
Residents reviewed: 6
Residents affected: 1
Residents reviewed: 12
Residents affected: 1
Expired milk cartons: 150
Dishwasher sanitizer level: 10
Dishwasher wash temperature: 130
Hot dog temperature: 58
Mashed potatoes temperature: 107
Soup temperature: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #29 | Licensed Practical Nurse | Administered incorrect dose of Metformin |
| Dietary aide #13 | Dietary Aide | Observed wiping soiled dishes and dishwasher checks |
| Cook #12 | Cook | Prepared food with improper portion sizes and reheated food improperly |
| DTR #18 | Registered Diet Technician | Interviewed regarding nutrition and food service issues |
| RD #19 | Registered Dietitian | Interviewed regarding nutrition and food service issues |
| Food Service Director | Food Service Director | Responsible for food service operations and training |
| Administrator | Facility Administrator | Interviewed regarding facility operations and deficiencies |
| Regional RD #20 | Regional Registered Dietitian | Interviewed regarding nutrition oversight |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 17, 2021
Visit Reason
One Level 0 deficiency for criminal history record check process with no harm indicated.
Findings
One Level 0 deficiency for criminal history record check process with no harm indicated.
Deficiencies (1)
Criminal history record check process
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