Inspection Reports for
Pontiac Nursing Home
303 East River Road, Oswego, NY, 13126
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
14.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
184% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 12
Date: Sep 12, 2025
Visit Reason
Inspection identified 12 health citations and no life safety code citations, with multiple Level 2 deficiencies related to quality of care and resident rights.
Findings
Inspection identified 12 health citations and no life safety code citations, with multiple Level 2 deficiencies related to quality of care and resident rights.
Deficiencies (12)
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Infection prevention & control
Nutrition/hydration status maintenance
Nutritive value/appear, palatable/prefer temp
Qrtly assessment at least every 3 months
Quality of care
Resident rights/exercise of rights
Respiratory/tracheostomy care and suctioning
Services provided meet professional standards
Use of outside resources
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Sep 12, 2025
Visit Reason
The visit was a recertification and abbreviated survey conducted to assess compliance with food safety and sanitation standards in the facility's food services.
Findings
The facility failed to ensure food was properly cooled, stored, served at appropriate temperatures, and that nutrition rooms and storage areas were maintained in a clean and sanitary condition. Multiple violations related to improper cooling, food storage, hot holding temperatures, and unsanitary conditions were observed.
Deficiencies (4)
F0812: The facility did not ensure prepared foods were cooled properly, with documented temperatures above required limits and no corrective actions taken. The facility lacked food storage, food service, food handling, and pest policies.
Raw eggs were stored above ready-to-eat items in a refrigerator, posing a risk of cross-contamination. Staff were unaware of proper storage requirements and corrected the placement after observation.
Hot holding temperatures on the steam table were inadequate, with some foods served below 140 degrees Fahrenheit and one bay not turned on during meal service.
Nutrition rooms and storage areas were unsanitary, including spills and leaks in the walk-in cooler and nourishment room, with food debris and potential pest harborage present.
Report Facts
Dates of improper cooling temperatures: 6
Temperatures observed on steam table: Tomato soup at 156°F, grilled cheese at 130°F, gravy at 90°F, mashed potatoes at 108°F, riblets at 122°F
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Provided statements regarding cooling times, food storage policies, and hot holding procedures. | |
| Rehab Director | Noted improper storage of raw eggs above ready-to-eat items. | |
| Dietary Aide #32 | Reported that the third bay on the steam table did not work and discussed hot holding practices. | |
| Environmental Services Director | Unaware of leaks and unsanitary conditions in nourishment rooms and walk-in cooler. |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Sep 12, 2025
Visit Reason
The survey was a recertification survey conducted from 9/8/2025 to 9/12/2025 to assess compliance with regulatory requirements for Pontiac Nursing Home.
Findings
The facility was found deficient in multiple areas including residents' rights and dignity, timely and comprehensive assessments, care planning, medication administration, respiratory care, nutrition and hydration, food safety and sanitation, infection control, and provision of outside professional services.
Deficiencies (12)
F 0550: The facility failed to ensure residents' right to a dignified existence and self-determination, including improper involvement of family in financial decisions and restrictions on residents' use of cell phones and outdoor access.
F 0638: The facility did not ensure quarterly Minimum Data Set assessments were completed timely for two residents.
F 0656: The facility failed to develop and implement comprehensive person-centered care plans for four residents, missing key needs such as bed rails, urinary catheter care, and behavioral and diabetes management.
F 0658: The facility failed to ensure professional standards of quality in medication administration for two residents, including late administration of long-acting insulin and failure to prime insulin pens.
F 0684: The facility failed to provide care and treatment according to orders for one resident with a change in condition, including lack of timely assessment, documentation, and provider notification regarding oxygen therapy and chest x-ray.
F 0689: The facility did not ensure a resident on a nectar thick liquid diet received proper diet consistency, was not referred timely to speech language pathology, and was non-compliant without adequate interventions.
F 0692: The facility failed to maintain acceptable nutritional status for two residents, including inadequate nutritional assessments, improper tube feeding orders, and lack of supervision for self-administered tube feeding.
F 0695: The facility failed to provide safe and appropriate respiratory care for one resident using a continuous positive airway pressure machine without physician orders, care plan, or cleaning protocol.
F 0804: The facility failed to ensure food was palatable and served at an appetizing temperature, including serving burnt grilled cheese sandwiches.
F 0812: The facility failed to procure, store, prepare, distribute, and serve food in accordance with professional standards, including improper cooling, food storage, hot holding temperatures, and unsanitary conditions in food storage and nourishment areas.
F 0840: The facility failed to employ or obtain outside professional resources to provide services when not employed, including failure to follow up on a vascular test recommendation for a resident with leg wounds.
F 0880: The facility failed to provide and implement an infection prevention and control program, including staff not wearing required personal protective equipment and failure to perform hand hygiene in a contact precaution room.
Report Facts
Weight loss: 14
Weight loss: 9
Temperature: 156
Temperature: 130
Temperature: 90
Temperature: 108
Temperature: 122
Tube feeding volume: 237
Tube feeding volume: 270
Tube feeding volume: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #9 | Involved in medication administration and oxygen therapy findings. | |
| Registered Nurse Supervisor #4 | Responsible for care plan oversight, medication administration, and infection control. | |
| Certified Nurse Aide #17 | Provided resident care and interviewed regarding outdoor access and diet compliance. | |
| Licensed Practical Nurse #5 | Observed medication administration and interviewed about insulin administration. | |
| Wound Nurse Practitioner #20 | Provided wound care and recommended ankle-brachial index testing. | |
| Food Service Director | Interviewed regarding food service and sanitation deficiencies. | |
| Registered Dietitian #6 | Provided nutritional assessments and recommendations. | |
| Registered Nurse Supervisor/Infection Control Nurse #8 | Provided infection control education and oversight. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 12
Date: Feb 15, 2024
Visit Reason
Inspection identified 8 health citations and 4 life safety code citations with multiple Level 2 deficiencies, many corrected by April 3, 2024.
Findings
Inspection identified 8 health citations and 4 life safety code citations with multiple Level 2 deficiencies, many corrected by April 3, 2024.
Deficiencies (12)
ADL care provided for dependent residents
Encoding/transmitting resident assessments
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Influenza and pneumococcal immunizations
Investigate/prevent/correct alleged violation
Label/store drugs and biologicals
Nutritive value/appear, palatable/prefer temp
Corridors - construction of walls
Elevators
Hazardous areas - enclosure
Sprinkler system - maintenance and testing
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Feb 15, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulations related to resident abuse investigations and activities of daily living care.
Complaint Details
The visit included a complaint investigation related to an allegation by Resident #17 that a certified nurse aide punched them in the leg. The allegation was not properly investigated, witness statements were not obtained, and the medical provider and family were not notified as required. The facility acknowledged failures in investigation and notification.
Findings
The facility failed to timely investigate an allegation of abuse involving Resident #17 and did not remove the alleged perpetrator from resident access pending investigation. Additionally, Resident #6 did not receive scheduled showers or proper nail care, risking health decline and infections.
Deficiencies (2)
F 0610: The facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated and did not prevent further potential abuse for Resident #17. The alleged abuse was not investigated timely and the alleged perpetrator was not removed from resident access pending investigation.
F 0677: The facility did not ensure Resident #6 received necessary services to maintain good nutrition, grooming, and personal hygiene. Resident #6 was observed with dirty and untrimmed fingernails and was not provided a shower as planned.
Report Facts
Residents affected: 1
Residents affected: 1
Date survey completed: Feb 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #6 | Reported alleged abuse to Director of Nursing and interviewed regarding abuse investigation | |
| Certified Nurse Aide #13 | Alleged perpetrator of abuse to Resident #17 | |
| Director of Nursing | Responsible for investigation and notification of abuse allegations | |
| Nurse Practitioner #15 | Responsible for medical assessment of Resident #17, not notified of abuse allegation | |
| Social Worker #3 | Involved in abuse investigation and interviewed | |
| Certified Nurse Aide #11 | Interviewed regarding shower and nail care schedules | |
| Registered Nurse #4 | Responsible for updating shower sheets and interviewed about care | |
| Certified Nurse Aide #17 | Observed Resident #6's nails and interviewed about care |
Inspection Report
Recertification
Deficiencies: 8
Date: Feb 15, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements for Pontiac Nursing Home.
Findings
The facility was found deficient in multiple areas including failure to properly investigate and prevent potential abuse, late submission of Minimum Data Set assessments, inadequate personal care for residents, improper storage of controlled medications, serving food at unsafe temperatures, improper food storage and sanitation, failure to maintain infection control protocols, and failure to ensure residents were offered influenza vaccinations with proper documentation.
Deficiencies (8)
F 0610: The facility failed to timely investigate an allegation of abuse for Resident #17 and did not remove the alleged perpetrator from resident access pending investigation.
F 0640: The facility did not electronically submit accurate and complete Minimum Data Set assessments within 14 days for 11 residents, including Resident #17.
F 0677: Resident #6 was not provided scheduled showers or nail care, resulting in poor hygiene and risk for infection.
F 0761: Controlled medications on Unit 2 were stored in an untethered medication cart and not returned to the locked cabinet after medication passes.
F 0804: Food served during lunch on 2/13/2024 and breakfast on 2/14/2024 was not at palatable or safe temperatures as required by policy.
F 0812: The facility had expired and undated food items in the main kitchen and first-floor kitchenette, and unclean cooking pans on the drying rack.
F 0880: Staff failed to consistently follow infection prevention and control protocols including proper use and removal of personal protective equipment and hand hygiene for residents on droplet and contact precautions.
F 0883: The facility did not ensure residents #11 and #43 were offered influenza immunizations or documented education and declination for the 2023-2024 season.
Report Facts
Residents with late Minimum Data Set assessments: 11
Controlled medications count: 5
Expired or undated food items: 7
Residents on droplet/contact precautions: 3
Residents reviewed for influenza immunization: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Reported alleged abuse to Director of Nursing and provided statements about Resident #17 abuse investigation |
| Director of Nursing | Director of Nursing | Involved in abuse investigation, medication storage oversight, infection control, and influenza vaccination tracking |
| Licensed Practical Nurse #10 | Licensed Practical Nurse | Observed leaving controlled medications unattended in medication cart and improper infection control practices |
| Nurse Practitioner #15 | Nurse Practitioner | Involved in abuse investigation and infection control observations |
| Certified Nurse Aide #13 | Certified Nurse Aide | Alleged perpetrator in abuse allegation involving Resident #17 |
| Certified Nurse Aide #19 | Certified Nurse Aide | Observed improper infection control practices with isolation gowns and gloves |
| Food Service Director | Food Service Director | Reported on food temperature monitoring and food storage deficiencies |
| Administrator | Administrator | Provided statements on abuse reporting and influenza vaccination policies |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 11, 2023
Visit Reason
Annual inspection survey of Pontiac Nursing Home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Dec 22, 2021
Visit Reason
Inspection identified 2 health citations with Level 2 deficiencies related to abuse and neglect and notification of changes, both corrected by January 25, 2022.
Findings
Inspection identified 2 health citations with Level 2 deficiencies related to abuse and neglect and notification of changes, both corrected by January 25, 2022.
Deficiencies (2)
Free from abuse and neglect
Notify of changes (injury/decline/room, etc. )
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 14, 2021
Visit Reason
The inspection was a recertification survey conducted from 10/12/21 to 10/14/21 to assess compliance with federal and state regulations for Pontiac Nursing Home.
Findings
The facility was found deficient in multiple areas including failure to provide timely nail care, inadequate treatment and care for skin conditions and use of physician-ordered TED stockings, failure to arrange for an optometry consult, failure to maintain residents' nutritional status and weight monitoring, expired medications and biologicals in medication storage, and lack of carbon monoxide detection in the basement.
Deficiencies (6)
F 0677: The facility failed to ensure residents unable to perform activities of daily living received necessary services for grooming and personal hygiene, specifically Resident #21 was not provided timely nail care.
F 0684: The facility failed to provide appropriate treatment and care according to orders for Residents #4 and #26, including untreated excoriated skin and failure to apply physician-ordered TED stockings.
F 0685: The facility failed to assist Resident #19 in gaining access to vision services by not making arrangements for a physician-ordered optometry consult.
F 0692: The facility failed to maintain acceptable nutritional status and monitor significant weight changes for Residents #26 and #236, including lack of timely reassessment and incomplete weight monitoring.
F 0761: The facility failed to label drugs and biologicals properly and had expired medications and biologicals in the Unit 1 medication room refrigerator.
F 0836: The facility failed to provide carbon monoxide detection in the basement where fuel burning equipment was located, and lacked policy and training for CO alarm activation.
Report Facts
Residents reviewed: 3
Residents reviewed: 1
Residents reviewed: 4
Expired medication doses: 150
Weight gain percentage: 11
Weight gain percentage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in findings related to skin care and TED stockings application |
| LPN #6 | Licensed Practical Nurse | Named in findings related to TED stockings application and medication storage |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding care expectations and deficiencies |
| Nurse Practitioner #12 | Nurse Practitioner | Interviewed regarding TED stockings and weight monitoring |
| Nurse Practitioner #16 | Nurse Practitioner | Interviewed regarding weight monitoring |
| Director of Nursing | Director of Nursing | Interviewed regarding medication storage and expired medications |
| Food Service Director | Food Service Director | Interviewed regarding weight monitoring and nutritional assessments |
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