Onondaga Center For Rehabilitation And Nursing

F 0684 Level of Harm - Minimal harm or potential for actual harm

roommate. Licensed Practical Nurse #21 went into the resident's room, checked their safety, and took vitals.

They documented the resident stated they went to the bathroom, then felt dizzy and sat on the floor. They notified the supervisor (unnamed) at 6:30 PM.-on [DATE REDACTED] at 6:00 PM, Licensed Practical Nurse #9 documented they heard about the incident from the staff. Staff reported the resident was in the bathroom

on the floor. The supervisor (unnamed) was notified at 6:52 PM by Licensed Practical Nurse #9.

Residents Affected - Few Resident #85 expired on [DATE REDACTED] at 6:02 AM.During an interview on [DATE REDACTED] at 11:35 AM, Certified Nurse Aide #30 stated the resident had a fall on [DATE REDACTED] in the evening while attempting to use the bathroom on their own. They were found on the floor in the bathroom. Resident #85 had two falls on [DATE REDACTED], once in the bathroom, and another next to the bed. The resident was assessed before being assisted off the floor using

a mechanical lift. They could not recall who assessed the resident. They did not have a registered nurse in

the building during the 2:00 PM –10:00 PM shift, so they had to call someone for a video call. During

a telephone interview on [DATE REDACTED] at 2:19 PM, Licensed Practical Nurse #21 stated they did not recall any falls for Resident #85. If a resident had a fall, they checked on them, checked to see if it was safe, and checked for injury. The supervisor needed to assess the resident. The registered nurse would do the assessment. 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. They would notify the medical providers, and document in the resident's chart about the fall and who they spoke to.

During a telephone interview on [DATE REDACTED] 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 REDACTED] 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

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Onondaga Center for Rehabilitation and Nursing

217 East Avenue Minoa, NY 13116

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

they were supposed to use the call light, but they could not reach it. At 2:01 PM, the resident was in bed and there was one fall mat on the floor between the bed and window. The Acting Director of Nursing was in

the room to check the resident's oxygen. At 2:04 PM, the resident's call light was under the bed not within reach. -on 09/25/2025 at 11:44 AM lying in bed with their call light under the cross bar under the bed. There was no fall mat on the side between the resident's bed and their roommate's bed. The second fall mat was folded behind the resident's wheelchair. Certified Nurse Aide #28 entered the resident's room to provide care. At 12:01 PM, Certified Nurse Aide #28 left the resident's room, and the call light was on the floor underneath the resident's bed. -on 09/29/2025 at 1:43 PM in bed with only one fall mat on the floor and the other folded up. Their resident's call light was on the floor out of reach.

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)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet