Resident #85 fell twice on the day before their death at Onondaga Center for Rehabilitation and Nursing. The first fall occurred in the bathroom while the resident attempted to use it alone. The second happened next to their bed.
Certified Nurse Aide #30 found the resident on the bathroom floor during the evening. Staff used a mechanical lift to assist the resident off the floor after an assessment, though the aide could not recall who performed that evaluation.
The facility had no registered nurse in the building during the 2:00 PM to 10:00 PM shift. Staff had to arrange a video call for the assessment instead.
Licensed Practical Nurse #21, who worked that evening, initially told inspectors they did not recall any falls involving Resident #85. When pressed about fall protocols, the nurse explained they would check on residents, assess safety, and look for injuries. A supervisor was supposed to evaluate the resident, preferably a registered nurse.
"If there was no registered nurse in the building, they should call the on-call registered nurse and inform them about the fall and they could video call for the assessment," the LPN said.
The nurse said they would notify medical providers and document the incident in the resident's chart.
But the documentation tells a different story about when supervisors learned of the falls.
Licensed Practical Nurse #21 documented that another resident reported hearing something at 6:00 PM. The nurse went into Resident #85's room, checked their safety, and took vitals. The resident told the nurse they had gone to the bathroom, felt dizzy, and sat on the floor. The supervisor was notified at 6:30 PM.
A second incident report shows Licensed Practical Nurse #9 heard about a fall from staff at 6:00 PM that same evening. Staff reported the resident was on the bathroom floor. That supervisor wasn't notified until 6:52 PM.
Assistant Director of Nursing #22 acknowledged that Resident #85 experienced multiple falls but could not recall when they occurred. The assistant director described the video call process for when no medical staff was in the building.
"If medical was not in the building, they could do a video call to allow them to get a visual of the resident," the assistant director explained. Through video, medical staff could ask the resident to move limbs, view their skin, check for bleeding, and have the on-site nurse complete a neurological assessment.
The assistant director said they never completed a video call for Resident #85. Despite knowing the resident had fallen before dying, the assistant director was not part of any investigation or assessment.
Director of Nursing confirmed the facility's protocol for handling incidents when no registered nurses were present. Staff should contact telehealth services with the Medical Director, call the provider for visual assessment and orders, and notify the registered nurse.
The director said they had provided education for staff to contact the medical provider first when using telehealth services. Any telehealth consultation should generate documentation in progress notes or be uploaded to the resident's file.
No evidence appeared in the inspection report that such documentation existed for Resident #85's falls.
The resident died approximately 12 hours after the evening falls, at 6:02 AM the following morning.
Federal regulations require nursing homes to ensure adequate nursing coverage and proper assessment of residents who experience falls or injuries. The facility's reliance on video consultations during evening hours, when no registered nurse was physically present, raises questions about the adequacy of care provided to vulnerable residents.
The inspection found the facility failed to ensure residents received proper assessment and care following incidents, particularly when qualified nursing staff were not immediately available on-site.
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.
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