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🔎 Cayuga Nursing And Rehabilitation Center

Inspection Results


Inspection Overview

Cayuga Nursing And Rehabilitation Center has been cited for a total of 74 deficiencies since we began saving each survey.

In New York, the average facility has **24.69 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

Survey Date: 2025-01-24
Correction Date: 2025-03-25
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2025-01-24
Correction Date: 2025-03-25
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Plan the resident's discharge to meet the resident's goals and needs.

Survey Date: 2025-01-24
Correction Date: 2025-03-25
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2025-01-24
Correction Date: 2025-03-25
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2025-01-24
Correction Date: 2025-03-25
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2025-01-24
Correction Date: 2025-03-25
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2025-01-24
Correction Date: 2025-03-25
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2025-01-24
Correction Date: 2025-03-25
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2025-01-24
Correction Date: 2025-03-25
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2025-01-24
Correction Date: 2025-01-24
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Survey Date: 2023-10-18
Correction Date: 2023-12-17
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Survey Date: 2023-06-08
Correction Date: 2023-08-07
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2023-06-08
Correction Date: 2023-08-07
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2023-06-08
Correction Date: 2023-08-07
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-06-08
Correction Date: 2023-08-07
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2023-06-08
Correction Date: 2023-08-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-06-08
Correction Date: 2023-08-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2023-06-08
Correction Date: 2023-08-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-06-08
Correction Date: 2023-08-07
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2023-06-08
Correction Date: 2023-08-07
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2023-06-08
Correction Date: 2023-08-07
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Make sure that a working call system is available in each resident's bathroom and bathing area.

Survey Date: 2023-06-08
Correction Date: 2023-08-07
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2023-06-08
Correction Date: 2023-08-07
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2023-06-08
Correction Date: 2023-08-07
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-05-26
Correction Date: 2023-07-21
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2023-05-26
Correction Date: 2023-07-21
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2021-07-30
Correction Date: 2021-09-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2021-07-30
Correction Date: 2021-09-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2021-07-30
Correction Date: 2021-09-28
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-07-30
Correction Date: 2021-09-28
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2021-07-30
Correction Date: 2021-09-28
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Survey Date: 2021-07-30
Correction Date: 2021-09-28
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2021-07-30
Correction Date: 2021-09-28
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2021-03-18
Correction Date: 2021-05-17
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2020-10-02
Correction Date: 2020-10-30
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are fully informed and understand their health status, care and treatments.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Allow residents to self-administer drugs if determined clinically appropriate.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure residents have reasonable access to and privacy in their use of communication methods.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Assure that each resident’s assessment is updated at least once every 3 months.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Assist a resident in gaining access to vision and hearing services.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Have a plan that describes the process for conducting QAPI and QAA activities.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Survey Date: 2019-06-20
Correction Date: 2019-08-13
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Implement a program that monitors antibiotic use.

Survey Date: 2019-06-20
Correction Date: 2019-08-30
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Survey Date: 2017-12-05
Correction Date: 2018-02-03
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2017-12-05
Correction Date: 2018-02-03
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2017-12-05
Correction Date: 2018-02-03
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2017-12-05
Correction Date: 2018-02-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2017-12-05
Correction Date: 2018-02-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Assist a resident in gaining access to vision and hearing services.

Survey Date: 2017-12-05
Correction Date: 2018-02-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2017-12-05
Correction Date: 2018-02-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2017-12-05
Correction Date: 2018-02-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2017-12-05
Correction Date: 2018-02-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Survey Date: 2017-12-05
Correction Date: 2018-02-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2017-12-05
Correction Date: 2018-02-03
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide or get specialized rehabilitative services as required for a resident.

Survey Date: 2017-12-05
Correction Date: 2018-02-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2017-12-05
Correction Date: 2018-02-03
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**