Northwoods Rehab And Nursing Center At Moravia
NORTHWOODS REHAB AND NURSING CENTER AT MORAVIA in MORAVIA, NY — inspection on November 18, 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.
Inspection Findings
During an interview on 9/24/2025 at 2:20 PM, Physician #18 stated if intravenous antibiotics were not administered, they should be called. A provider should always be notified.
They do not recall Resident #32 as some time had passed.
They did recall Resident #45.
They expected Resident #45 to receive their intravenous antibiotic that was ordered for an infection to the finger that required a partial amputation.
They were not notified the resident did not have their antibiotic administered.
If they were notified of a missed antibiotic dose, they would have changed the order to have it be given intramuscularly. If a resident did not receive intravenous antibiotics, it would be a significant medication error. If the nurse did not notify them and did not get an intramuscular order to have it replaced with, it would be neglect.
Without the antibiotic the resident may have required additional amputation.
During an interview on 9/24/2025 at 3:20 PM, former Director of Nursing #6 stated Resident #45 had a finger amputation and arrived back at the facility with a peripherally inserted central catheter and intravenous antibiotics.
Licensed practical nurses were not allowed to administer intravenous antibiotics and registered nurses performed all the care for peripherally inserted central catheters.
When they found the medication administration was missing, they notified the physician, however they did not recall if they documented that.
They did not recall if other medication administration records for other residents in the facility were reviewed.
They did not know if neglect was ruled out because they were not able to continue the investigation as it was taken over by the Administrator.
They did not recall anything regarding Resident #32's clonazepam as some time had passed.
They were not sure if Registered Nurse #16 had been reported to the state for falsification of documentation, but they should have been.
During an interview on 9/25/2025 at 1:00 PM, the Administrator stated they had training on abuse and neglect.
They were responsible for reporting certain specific cases of abuse and neglect to the Department of Health.
They were the facility Administrator at the time of the medication errors with both Resident #45 and Resident #32.
The investigation started with former Director of Nursing #6 and they took over.
They were not sure what was done to ensure medications were not missed for other residents.
They were not sure if the missed administrations was neglect, however it was a significant medication error.
Significant medication errors were reported to the state; however, they did not report it as they were new to their roll and was going through a rough situation. In hindsight they would have done things differently. 10NYCRR 415.4(b)(3)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/18/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Northwoods Rehab and Nursing Center at Moravia
7 Keeler Avenue Moravia, NY 13118
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 9/24/2025 at 1:43 PM, Director of Nursing #2 stated only registered nurses administered intravenous antibiotics. If medications were not given the provider should be notified and then documented in a progress note. If it was noticed that a nurse did not administer medications to one resident, they looked at all medication administration records for all residents and medication blister packs to ensure medications were given to other residents.
Failure to administer medications required an investigation to rule out neglect or abuse.
They were not employed by the facility at the time of the incidents with Resident #32 or Resident #45.
During an interview on 9/24/2025 at 2:20 PM, Physician #18 stated if intravenous antibiotics were not administered, they should be called. A provider should always be notified.
They did not recall Resident #32 but recalled Resident #45.
They expected Resident #45 to receive their ordered intravenous antibiotic for an infection to the finger that required a partial amputation.
They were not notified the resident did not have their antibiotic administered. If they were notified of a missed antibiotic dose, they would change the order to have it administered intramuscularly. If a resident did not receive intravenous antibiotics, it would be a significant medication error.
Without the antibiotic the resident may have required additional amputation.
During an interview on 9/24/2025 at 3:20 PM, former Director of Nursing #6 stated Resident #45 had a finger amputation and arrived back at the facility with a peripherally inserted central catheter (venous access) and intravenous antibiotics.
Licensed practical nurses were not allowed to administer intravenous antibiotics and registered nurses performed all the care for peripherally inserted central catheters.
When they found the medication administration was missing, they notified the physician, however they did not recall if they documented that.
They did not recall if other medication administration records for other residents in the facility were reviewed.
They did not recall anything regarding Resident #32's clonazepam as some time had passed.
They were not sure if Registered Nurse #16 was reported to the state for falsification of documentation, but they should have been.An attempt to contact Registered Nurse #16 on 09/25/2025 at 3:43 PM was unsuccessful.
The number provided by the facility was no longer in service. 10NYCRR 415.12(m)(2)
Facility ID:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.