Onondaga Center: Accident Hazard Violations - NY
Federal inspectors documented three separate instances in September where the resident's call light was inaccessible, despite care plan requirements that it remain within reach at all times. Staff also failed to maintain required fall safety equipment at the bedside.
On September 23rd at 2:01 PM, inspectors found the resident in bed with their call light under the bed, completely out of reach. Only one fall mat was positioned on the floor between the bed and window, though the resident's care plan required two mats.
The Acting Director of Nursing was present in the room checking the resident's oxygen when inspectors made their observation. Three minutes later, at 2:04 PM, the call light remained under the bed.
Two days later, inspectors returned to find the same safety violations. On September 25th at 11:44 AM, the resident lay in bed with their call light positioned under the cross bar beneath the bed frame. No fall mat protected the space between the resident's bed and their roommate's bed. The second required fall mat was folded up behind the resident's wheelchair, useless for fall prevention.
Certified Nurse Aide #28 entered the room to provide care but failed to correct the safety hazards. When the aide left at 12:01 PM, the call light remained on the floor underneath the resident's bed.
The pattern continued four days later. On September 29th at 1:43 PM, inspectors documented the resident in bed with only one fall mat on the floor and the other folded up, their call light again on the floor out of reach.
During interviews, nursing staff acknowledged the violations but offered conflicting explanations.
Registered Nurse #24 told inspectors that the resident's care plan required fall mats, using the plural form, though it didn't specify exactly how many. The nurse confirmed that fall mats should remain in place whenever the resident was in bed, and that the call light should always be within reach.
Certified Nurse Aide #28 provided a different account when questioned about the September 25th incident. The aide claimed the resident's call light was actually within reach and that they had just picked it up and placed it on the bed. They also said they had positioned the bed in its lowest setting.
However, the aide's statement directly contradicted what inspectors had observed moments earlier. When the aide left the room at 12:01 PM, inspectors documented the call light remaining on the floor under the bed.
The aide offered an explanation for the missing fall mat, suggesting it was likely removed to provide the resident their meal tray. Someone who picked up the tray after the meal failed to replace the safety equipment, the aide said. They acknowledged the mat should have been returned to position after the resident finished eating.
The aide confirmed that Resident #80 was supposed to have two fall mats in place according to their care plan, and that staff determined fall precaution requirements by consulting each resident's individualized care plan.
The repeated safety violations left the resident unable to call for help if needed and without proper fall protection equipment. Call lights serve as residents' primary means of summoning assistance for medical emergencies, bathroom needs, or other urgent situations.
Fall mats provide cushioning if residents attempt to get out of bed unassisted, potentially preventing serious injuries from falls onto hard flooring.
The inspection findings represent a pattern of neglect rather than isolated incidents, with staff failing to maintain basic safety protocols across multiple days and shifts. The resident remained at risk each time their call light was inaccessible and required fall protection equipment was improperly stored or missing entirely.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Onondaga Center For Rehabilitation and Nursing from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Onondaga Center for Rehabilitation and Nursing in MINOA, NY was cited for violations during a health inspection on November 20, 2025.
Staff also failed to maintain required fall safety equipment at the bedside.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.