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Complaint Investigation

Onondaga Center For Rehabilitation And Nursing

November 20, 2025 · Minoa, NY · 217 East Avenue
Citations 2
CMS Rating 1/5
Beds 82
Provider ID 335548
Healthcare Facility
Onondaga Center For Rehabilitation And Nursing
Minoa, NY  ·  View full profile →
Inspection Summary

Onondaga Center for Rehabilitation and Nursing in MINOA, NY — inspection on November 20, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0684
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

During a telephone interview on [DATE] at 12:26 PM, Assistant Director of Nursing #22 stated Resident #85 experienced a couple of falls but could not recall when. If they were notified of the fall, they would review the resident's vitals, call medical, and notify family. If medical was not in the building, they could do a video call to allow them to get a visual of the resident.

They could ask the resident to move limbs, view their skin, observe for bleeding, ask the nurse on site to complete a neurological assessment, and check length of limbs to see if there was a difference.

They never completed a video call for Resident #85. Resident #85 had a fall prior to expiring, but they were not part of the investigation or assessment.

During an interview on [DATE] at 12:32 PM, the Director of Nursing stated the process to complete an assessment if there were no registered nurses in the building was to contact telehealth with the Medical Director Services.

They should call the provider, and the provider could look at them and give orders.

They should contact the registered nurse and let them know.

They provided education for the staff to contact the Medical Provider first. If staff contacted the Medical Provider with telehealth there would be a telehealth note in the progress notes or uploaded.10NYCRR 415.12

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Onondaga Center for Rehabilitation and Nursing

217 East Avenue Minoa, NY 13116

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 09/25/2025 at 9:06 AM, Registered Nurse #24 stated the care plan or the Kardex (care instructions) contained what fall interventions a resident needed.

They stated Resident #80's care plan did not specifically state how many mats they were supposed to have at the bedside, but it did have mats as in plural.

The fall mats should be in place if the resident was in bed.

The resident's call light should always be in reach.

During an interview on 09/25/2025 at 12:01 PM, Certified Nurse Aide #28 stated they knew what fall precautions needed to be in place for a resident by the resident's care plan. If a resident's care plan documented to have fall mats in place, they should be in place. Resident #80 was supposed to have two fall mats in place.

The second fall mat was likely put up to provide the resident their tray and whoever picked up the tray did not replace it. It should have been replaced after the resident was finished with their meal.

They stated the resident's call light was in reach, they had just picked it up and put it on the bed as well as putting the bed in the lowest position. 10 NYCRR 415.12(h)(1)(2)

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MINOA, NY, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Onondaga Center for Rehabilitation and Nursing or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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