Oneida County Hospital & Long Term Care Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure the residents and their representatives received assistance to exercise their right to formulate an Advanced Directive. This was true for 2 of 12 residents (Resident #4 and #19) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning. Findings include:The facility's Resident Rights Regarding Treatment and Advance Directives policy, review date 6/5/25, documented: - On admission the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advance directive. - The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interviews it was determined the facility failed to ensure appropriate discharge planning was documented in the resident's medical record and appropriate resident information was communicated to the resident's representative for 1 of 1 resident (Resident #27) reviewed for discharge. This deficient practice had the potential to result in adverse outcomes or harm if the resident did not receive appropriate care after discharge. Findings include: The facility's Discharge Summary policy approved date 4/22/25, documented it is the policy of the facility to ensure that a discharge summary is provided upon a resident's discharge which addresses each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies. Resident #27 was admitted to the facility on [DATE], with multiple diagnoses including dementia and Parkinsonism. A progress note dated 3/31/26 at 11:06 AM, documented staff reported Resident #27 had a fever (101.4 F)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review it was determined the facility failed to refer residents for recommended further evaluation when residents were diagnosed with a major mental illness. This was true for 1 of 2 residents (Resident #2) reviewed for Pre-admission Screening and Resident Review (PASRR) Level II evaluations. This deficient practice had the potential to cause harm if residents' PASRR Level II recommendations for specialized services needs were not referred for evaluation and incorporated in the resident's care. Findings include:The facility's Resident Assessment - Coordination with PASRR Program policy, dated 8/18/25, documents 7. Recommendations, such as any specialized services, from a PASRR Level II determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses which included alcohol dependence with alcohol-induced persisting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness. This was true for 1 of 2 residents (Resident #1) reviewed for Pre-admission Screening and Resident Review (PASRR) Level I and Level II evaluations. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not evaluated by an appropriate state-designated authority. Findings include: The facility's Resident Assessment - Coordination with PASRR Program policy, dated 8/18/25, documents 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions.a. PASRR Level I - initial pre-screening that is completed prior to admission.2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interviews, and policy review it was determined the facility failed to ensure that prior to the placement of bed rails, a resident assessment was completed that included alternatives to bed rail use were attempted and how the alternatives failed to meet the resident's assessed needs.This was true for 1 of 12 residents (Resident #3) reviewed for bed rails.This failure created the potential for harm due to the risk for injury, entrapment and/or death. Findings include:The facility's Proper Use of Bed Rails policy, reviewed date 6/5/25, documented.Policy Explanation and Compliance Guidelines: Resident Assessment 2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. 3. The resident assessment must also assess the resident's risk from using bed rails. 6. Informed consent from the resident or resident representative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and review of employee personnel files, it was determined the facility failed to ensure each CNA's annual performance review was completed at least once every 12 months for 2 of 2 CNAs (#1and #2) whose personnel records were reviewed for sufficient and competent staffing. This failure created the potential for incompetent CNAs providing care and increased the risk for harm for all residents living in the facility. Findings include:On 5/13/26 at 10:17 AM, review of CNA #1's employee file documented her initial hire date was 10/18/23.CNA #1's employee file did not have documentation that an annual performance review had been done.On 5/13/26 at 10:25 AM, review of CNA #2's employee file documented her initial hire date was 4/24/09.CNA #2's employee file did not have documentation that an annual performance review had been done.On 5/13/26 at 10:48 AM, the HR Director stated the CNAs annual performance reviews had not been provided to her to include in the personnel files.On 5/13/26 at 10:52 AM, the DON stated the CNAs annual performance reviews had not been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, and the State Operations Manual, Appendix PP it was determined the facility failed to ensure nurse staffing information was accurate, posted daily for each shift, and included scheduled and actual hours. This failed practice had the potential to affect the 23 residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:State Operations Manual, Appendix PP revised on 7/23/25, documents.the facility posts the following information on a daily basis: facility name, current date, total number and actual hours worked by licensed and unlicensed nursing staff, and resident census. On 5/12/26 at 1:40 PM, the daily posted staffing sheets were reviewed for the months of November 2025 - May 2026, the following was observed:-No facility resident census included on the sheets for the 7 months reviewed -No weekend (Saturday and Sunday) daily posted staffing sheets completed for the 7 months reviewed -No actual licensed and unlicensed staff hours documented on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and policy review it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 1 of 5 residents (Resident #15) observed for infection control. These failures put residents at risk for cross contamination and infection. Findings include: The facility's Oxygen Administration and Monitoring policy dated 9/29/25, documented Policy Interpretation and Implementation 5. Keep delivery devices covered in plastic bag when not in use.Resident #15 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses which included chronic obstructive pulmonary disease (disease process which causes decreased ability of the lungs to perform their function) and heart failure. A physician order dated 3/11/25, documented Resident #15 was to wear her CPAP machine (provides positive airway pressure to help breathing) every night related to her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) was accurately completed prior to admission for 1 of 3 residents (Resident #15), and when a new mental health diagnosis was identified for 2 of 3 residents (#10 and #11), whose records wer reviewed for PASARR screenings. These failures created the potential for harm if residents required, but did not receive, specialized services for mental health while residing in the facility. Findings include: Appendix PP of the State Operation Manual, revised on 8/8/24, documented the PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders or intellectual disabilities and related conditions prior to admission to a nursing facility. A negative Level 1 screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on contract review, policy review, observation, and staff interview, it was determined the facility failed to ensure infection control surveillance was maintained for the contracted laundry services which processed residents' personal laundry. This deficient practice had the potential to impact 18 of 21 residents who had personal laundry services provided by the facility. This deficient practice placed residents at risk of infection from cross contamination. Findings include: The facility's contract with the off-site personal laundry vendor, dated 5/1/13, documented the service provided laundry pick-up, wash, dry, fold, steam press and delivery of laundry items. The laundry was hygienically cleaned and handled to prevent recontamination for dust and dirt during transport. Provided with the personal laundry vendor's contract was a copy of the vendor's equipment information, dated 2016, which documented a Whirlpool Front-Loading Automatic Washer, Use and Care Guide, noted to be designed to use only HE High Efficiency detergents. The facility's Handling of Soiled Linen policy,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to ensure the resident's pulse was monitored appropriately for residents who received blood pressure medication. This was true for 1 of 5 residents (Resident #21) who were reviewed for unnecessary medications. This failure created the potential for harm if residents experienced adverse effects from blood pressure medication. Findings include: The facility's policy for Vital Signs, dated 11/5/19, documented the following: * Licensed nurses are responsible for knowing the usual range of a resident's vital signs, analyzing and interpreting routine vital signs, and notifying the physician of abnormal findings. * An acceptable range for pulse was 60 to 100 beats per minute. * Vital signs were obtained by the nurse as indicated, when administering certain medications, or for monitoring the effectiveness of medications or therapies. * Certain cardiac drugs are given only when a resident's pulse or blood pressure is within…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were provided with the level of supervision necessary to prevent falls. This was true for 1 of 2 residents (Resident #14) reviewed for falls. This failure placed Resident #14 at risk of pain, bone fractures, brain damage, and other life changing injuries, as a result of falls. Findings include: The CMS State Operations Manual, Appendix PP, the Long Term Care Facility federal regulations and guidance to surveyors, describes a fall as unintentionally coming to rest on the ground, or other lower level, but not as a result of an overwhelming external force (e.g. resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person, or if he or she had not caught him/herself, is considered a fall. The facility's policy for Fall Risk Assessment, dated 1/7/20, documented the following: * The facility provided an environment free from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to ensure appropriate behavior and side effect monitoring was documented for residents receiving psychotropic medications. This was true for 2 of 5 residents (#5 and #21) reviewed for unnecessary medications and created the potential for harm if residents experienced adverse side effects or behaviors from unnecessary psychotropic medications. Findings include: The facility's policy for Psychotropic Medications, dated 11/5/19, documented the following: * Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). * The effects of the psychotropic medications, including the resident's physical, mental, and psychosocial well-being were evaluated on an ongoing basis, including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.