Onondaga Center for Rehabilitation and Nursing

Inspectors wroteBased on record review and interviews during the recertification survey conducted [DATE]-[DATE], the facility failed to provide cardiopulmonary resuscitation prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for one (1) of three (3) residents (Resident #85) reviewed. Specifically, Resident #85 had a physician order for cardiopulmonary resuscitation (chest compressions and rescue breathing when there is no pulse and/or respirations) and an advance directive for cardiopulmonary resuscitation to be attempted. On [DATE], Resident #85 was found without a pulse and was not breathing, and staff did not initiate cardiopulmonary resuscitation. The resident was pronounced deceased by Emergency Medical Services. [...]

Inspectors wroteBased on record review and interviews during the recertification survey conducted [DATE]-[DATE] the facility failed to promptly notify the ordering physician of laboratory results that fell outside of clinical reference ranges for 3 of 3 residents (Residents #41, #60 and #85) reviewed. Specifically:-Resident #85 had abnormal laboratory values on [DATE] and [DATE] that were not reviewed timely or assessed by the medical provider. -Resident #41 had a critical laboratory result on [DATE] with no documented provider notification until [DATE]. - Resident #60 had abnormal laboratory and a positive wound culture on [DATE]. The results were not reviewed until [DATE]. This resulted in the likelihood of serious injury, serious harm, or death that was Immediate Jeopardy to resident's health and safety for all residents with ordered laboratory tests.

Inspectors wroteBased on record review and interviews during the recertification and extended survey conducted 09/22/2025-11/20/2025, the facility did not ensure the services provided or arranged by the facility were delivered by individuals who had skills to do a particular task in accordance with each resident's written plan of care for 38 resident's with orders for cardio-pulmonary resuscitation (perform chest compressions in the absence of a heartbeat). Specifically, staff with current cardio-pulmonary resuscitation certification that met accepted national standards were not present in the building twenty-four hours per day.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 09/22/2025-11/20/2025 the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for one (1) of one (1) main kitchen and one (1) of one (1) dining room. Specifically, in the main kitchen prepared foods were not cooled properly, multiple boxes of food items were stored on the floor, food items were not dated, and areas of the kitchen were unclean; and the dining room had unclean and sticky floors, and multiple trays from the previous meal were stacked on a rolling rack.

Inspectors wroteBased on observations, record review, and interviews during the recertification and extended survey conducted 09/22/2025 - 11/20/2025, the facility failed to ensure its operations were administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, administration's actions, inactions, or decisions contributed to deficient practices rising to Immediate Jeopardy in F678, Cardiopulmonary Resuscitation and F773, Laboratory Notifications. Additionally, administration failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (F726, Competent Nursing Staff).

Inspectors wroteBased on record review and interviews during the recertification survey conducted 09/22/2025- 11/20/2025, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for two (2) of three (3) residents (Residents #94 and #95) reviewed. Specifically, Residents #94 and #95 were discharged to home after discontinuation of Medicare Part A services and the facility did not provide the resident with the Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) for Medicare Part A as required.

Inspectors wroteBased on record review and interviews during the recertification survey conducted [DATE] -[DATE], the facility did not ensure all investigations were reported to the State Survey Agency within five (5) working days of the incident for one (1) of three (3) residents (Resident #85) reviewed. Specifically, cardiopulmonary resuscitation was not initiated for Resident #85 per their Medical Orders for Life Sustaining Treatment and was not reported to the New York State Department of Health as required. Refer to F678 (Cardiopulmonary Resuscitation).

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted [DATE]-[DATE], the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care person-centered care plan, and the resident's choices for one (one) of three (3) residents (Resident #85) reviewed. Specifically, Resident #85 had an unwitnessed fall on [DATE] at 6:00 PM and there was no documented evidence the resident was assessed by a qualified professional.

Inspectors wroteBased on record review, observations, and interviews during the recertification and abbreviated (#2565048) surveys conducted 09/22/2025-11/20/2025, the facility did not ensure residents received adequate supervision to prevent accidents for two (2) of three (3) residents (Residents # 70 and #80) reviewed. Specifically, Resident #70's physician orders documented aspiration precautions (used to prevent food, fluids, or secretions from entering the airway) with no straws, the resident was provided a straw during meals and was not assisted with meals as care planned; Resident #80 did not have planned fall interventions in place and their call bell was not in reach.

Inspectors wroteBased on record review and interview during the extended recertification survey conducted 09/22/2025-11/20/2025, the facility failed to ensure that licensed nurses had the appropriate competencies and skill sets necessary to provide nursing care and related services to assure residents safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident for five (5) of five (5) licensed nurses (Licensed Practical Nurses #6, #7, #10, #27, and #29) reviewed. Specifically, Licensed Practical Nurse #29 performed feeding tube care for Resident #5 that did not meet professional standards for infection control; and Licensed Practical Nurses #6, #7, #10, #27, and #29 did not have documented education or competencies completed annually in accordance with the needs identified in the Facility Assessment. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 09/22/2025-11/20/2025, the facility did not ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (3) of three (3) residents (Residents #5, #43, and #80) reviewed. Specifically, Resident #43's urinary catheter (drains urine from the bladder) collection bag was uncovered and laying directly on the floor without a barrier, and the resident did not have appropriate transmission-based precaution signage posted; Resident #5 was on enhanced barrier precautions and Licensed Practical Nurse #29 did not wear appropriate personal protective equipment when disconnecting the resident's tube feeding; [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted from 09/22/2025-11/20/2025, the facility did not ensure residents were informed during their stay of their rights and rules and regulations governing resident conduct and responsibilities eight (8) of ten (10) residents present at the Resident Group Meeting. Specifically, eight (8) anonymous residents in the resident meeting stated they were not aware of where information on the state complaint hotline, the ombudsman, or other pertinent State agencies were posted; they were not aware of their rights or where they were posted; and the State complaint hotline and other pertinent State agencies and advocacy groups were in small print and not posted at a resident accessible level.

Inspectors wroteBased on observations, record review, and interviews during the abbreviated survey (NY00364719), the facility failed to protect the resident's right to be free from physical abuse for 1 of 5 residents (Resident #1) reviewed. Specifically, Resident #1 was pushed by a staff member into a wall, causing a nosebleed and fractured nose. This resulted in harm, past noncompliance, to Resident #1 that was not Immediate Jeopardy.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure residents were treated with respect and dignity in a manner and environment that promotes maintenance or enhancement of quality of life for 6 of 11 residents (Residents #19, #36, #59, #379, and 2 anonymous residents) reviewed. Specifically, - Activities aide #7 and licensed practical nurse #2 had a verbal confrontation in front of Resident #19 after they ran out of portable oxygen during a group activity; - Certified nurse aide #8 stood over Resident #36 while assisting them with eating; - Resident #59 exhibited continuous disruptive verbal behaviors in a common area with other residents and was not removed from the space timely as planned. Additionally, the resident was transported in their wheelchair facing backwards by certified nurse aide #9; [...]

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00312922 and NY00340114) surveys conducted 5/6/2024-5/10/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 2 (North and South units) resident units and the main dining room. Specifically, on the North unit resident rooms [ROOM NUMBERS] had used incontinence briefs on the floor and nightstand; resident 209 smelled of urine; resident room [ROOM NUMBER]'s door handle was broken; and resident rooms [ROOM NUMBER] had sliding glass door restrictors that were not maintained. On the South unit resident rooms [ROOM NUMBERS] light fixtures were missing covers, had open light sockets, and exposed wiring; and there was a broken table in the main dining room. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00212922, NY00310702, and NY00310431) surveys conducted 5/6/2024-5/10/2024, the facility did not ensure 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 for 4 of 10 residents (Resident #1, #12, #35, and #37) reviewed. Specifically, Resident #1 was not assisted with dressing; Resident #12 was not assisted with bathing; Resident #35 was not assisted out of bed or supervised with meals; Resident #37 had unclean and untrimmed fingernails.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00312922) surveys conducted 5/6/2024-5/10/2024 the facility did not ensure 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 for 2 of 2 nursing units (North unit and South unit) observed. Specifically, resident meal trays were delivered to nursing floors up to 1 hour and 25 minutes after the scheduled mealtimes.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the main kitchen walk-in cooler floor and door, walk-in freezer door, hood filters, the wall beside the coffee station, and the ceiling were in disrepair and there were several unclean surfaces present throughout the kitchen.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00312922 and NY00310431) surveys conducted 5/6/2024-5/10/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 10 residents (Residents #36 and #45) reviewed and the facility lacked a water management plan to reduce the risk of growth and spread of Legionella (a bacteria found in water systems). Specifically, staff was observed not wearing the required personal protective equipment in Resident #45's room who was on transmission-based precautions; [...]

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not maintain equipment in safe operating condition for 2 of 2 unit kitchenette refrigerators. Specifically, the unit kitchenette refrigerators did not maintain proper temperatures.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate for 1 of 1 resident (Resident #45) reviewed. Specifically, Resident #45 had lidocaine-prilocaine cream (topical cream used to numb skin before a medical procedure) at their bedside and there was no documented evidence the resident was assessed for their ability to safely self-administer the medication.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 1 of resident (Resident #72) reviewed. Specifically Resident #72 did not have resident-specific interventions for their language barrier or for their potential to become a victim of verbal or physical abuse.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure ongoing provision of programs to support each resident in their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 2 residents (Residents #13 and #36) reviewed. Specifically, Residents #13 and #36 were not offered meaningful activities of their choosing as care planned. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00340114, NY00310431, NY00336364, and NY00310702) surveys the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 1 resident (Resident #60) reviewed. Specifically, Resident #60 had a recommendation for a follow up appointment with nephrology (kidney specialist) and there was no documented evidence the follow-up appointment was scheduled or occurred.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00312922 and NY00314056) surveys conducted 5/6/2024-5/10/2024 the facility did not ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for 2 of 9 residents (Residents #42 and #379) reviewed. Specifically, Resident #379's bed was not maintained in the low position and their call bell was not in reach and Resident #42 was observed wandering, unsupervised, into other resident rooms without interventions in place for monitoring

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00312922) surveys conducted 5/6/2024-5/10/2024, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 5 residents (Resident #75) reviewed. Specifically, Resident #75 was not weighed as ordered, did not received fortified pudding, and was not assisted with meals as care planned.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 of 1 resident (Resident #45) reviewed. Specifically, Resident #45 received hemodialysis (a treatment that filters the blood), had a physician order to remove the dialysis access site dressing 6-8 hours after dialysis and the dressing was scheduled to be removed prior to going to dialysis and was not completed.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable for 1 of 2 medication carts (Medication cart #2 on South unit) reviewed. Specifically, medication cart #2 on the South unit had an insulin lispro pen (short acting insulin) for Resident #25 that was not dated with an opened or expiration date; an insulin glargine pen (long acting insulin) for Resident #62 that was not dated with an opened or expiration date; and an Anoro Ellipta inhaler (used to treat chronic lung disease) for Resident #72 that was not dated with an opened or expiration date.

Inspectors wroteBased on observation and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and appetizing for 2 of 2 test trays (5/7/2024 and 5/8/2024 lunch trays) reviewed. Specifically, on 5/7/2024 the beef stew was 114 degrees Fahrenheit and the green and yellow bean mix was 108 degrees Fahrenheit; and on 5/8/2024 the French-fried potatoes were cold and undercooked.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure residents received and the facility provided a diet in a form designed to meet individual needs for 1 of 1 resident (Resident #33) reviewed. Specifically, Resident #33 was provided food items that were not consistent with their physician ordered diet.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure residents had a means of directly contacting staff for assistance for 1 of 1 resident (Resident #35) reviewed. Specifically, Resident #35's call bell was out of reach and not accessible.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not maintain an effective pest control program so that the facility was free of pests for 1 of 1 resident room. Specifically, there was evidence of mice in resident room [ROOM NUMBER].

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00310562 and NY00321915), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 3 of 4 residents (Residents #7, 9 and 10) reviewed. Specifically, , Resident #7 was admitted to the facility with a subdural hematoma (brain bleed) and there was no documentation a plan was implemented to monitor the resident for signs and s ymptoms of worsening subdural hematoma. Subsequently, Resident #7 exhibited a change in condition, was not assessed by a qualified professional, and was found unresponsive 12 hours later. The resident was sent to the hospital, diagnosed with an acute (sudden onset) left sided subdural hematoma that was larger in size, and the resident expired the next day. [...]

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00320770), the facility did not ensure services provided met professional standards of quality for 1 of 4 residents reviewed (Resident #8). Specifically, Resident #8 had orders to apply a condom catheter (urinary collection device) in the evening and the order was not implemented timely.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00324772), the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 was admitted with a continuous positive airway pressure machine (applies pressure to keep airway open when sleeping) and the facility did not clarify the hospital discharge instructions and did not consult with the medical provider to have the resident's need for the machine evaluated. The resident's continuous positive airway pressure machine was removed by the family prior to any clarification of the resident's needs.

Inspectors wroteBased on observation, interview and record review during the recertification and abbreviated surveys (NY00288852) conducted 3/6/22-3/14/22, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of quality of life for 72 of 78 residents reviewed. Specifically, on during the lunch meal on Sunday 3/6/22, residents received their food on disposable dishes. Additionally, during the resident group meeting 1 anonymous resident stated meals were frequently served on plastic disposable dishes on the weekends.

Inspectors wroteBased on observations, record reviews, and interviews during the recertification and abbreviated surveys (NY00262523, NY00280940, NY00270167, NY00288852, NY00276986, NY00282348, NY00283195, NY00285834 and NY00290976) conducted 3/6/22-3/14/22, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 11 residents (Residents #35, 50, 71 and 75) reviewed. Specifically, Resident #50 did not receive incontinence care as requested; Resident #71 did not receive assistance with care and transfers out of bed as requested and missed therapy; Resident #75 did not receive a shower on their designated/care planned day: and Resident #35 did not have their call bell answered timely.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00288852) surveys conducted 3/6/22- 3/14/22, the facility failed to ensure the resident menus were followed for 5 of 18 meals observed. Specifically, the facility ran out of preplanned menu items and substituted with items that were not nutritionally equivalent, served inadequate portion sizes, and did not inform the residents of menu substitutions.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00288852 and NY00270167) conducted 3/6/22-3/14/22, the facility failed to ensure food and drink was palatable, attractive, and at safe and appetizing temperatures for 2 meals observed and for 1 of 2 meal test trays. Specifically, the cranberry juice served at dinner on 3/8/22 was watered down and not palatable, the chicken noodle soup served at lunch on 3/8/22, was not attractive, and the test tray for the dinner meal on 3/7/22 was bland and not served at safe and appetizing temperatures. Additionally, Residents #13, 34, 37, 44, 50 and 75 and several anonymous residents during the resident group meeting stated the food was not palatable, appetizing, and was often served cold.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00288852) surveys conducted 3/6/22-3/14/22, the facility failed to ensure suitable, nourishing alternative meals and snacks were provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care for 2 of 2 nursing units (North Unit and South Unit) observed. Specifically, residents did not have snack items available on the nursing units.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 3/6/22-3/14/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 main kitchen reviewed. Specifically, the mechanical dishwasher was not clean and did not adequately sanitize dishware: expired milk was observed in the walk-in cooler for two days; and there was improper hot holding of hot dogs, mashed potatoes, and soup.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00292100 and NY00262523) conducted 3/6/22-3/14/22, the facility failed to ensure residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote the healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents (Resident #71) reviewed. Specifically, Resident #71 developed unstageable pressure ulcers (full-thickness tissue loss with the wound bed obscured by dead tissue) on their right and left heels and the planned intervention of heel protection boots was not consistently implemented.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00280940 and NY00285834) surveys conducted 3/6/22-3/14/22, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 6 residents (Resident #71) reviewed. Specifically, Resident #71 developed a pressure ulcer, and a timely nutritional assessment was not completed, and weights were not obtained as ordered.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00287009) surveys conducted 3/6/22-3/14/22, the facility failed to ensure residents are free of any significant medication errors for 1 of 12 residents (Resident #21) reviewed. Specifically, Resident #21 had a physician order for 1000 milligrams (mg) of Metformin (used to lower blood sugar) and was administered 500 mg of Metformin.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00288852) conducted 3/6/22-3/14/22, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 4 residents (Resident # 35) reviewed. Specifically, Resident #35 was not provided their soft salad sandwich at mealtime and was not offered a suitable substitution.