Minoa, New York — A central New York nursing home let a resident die last summer after staff ignored life-threatening lab results for days — and then withheld CPR despite a written order to do it. Afterward, management told staff not to report the incident to state health authorities, according to a state inspection report obtained by local media this week.
The facility, Onondaga Center for Rehabilitation and Nursing in Minoa, drew two separate “immediate jeopardy” citations from state inspectors — the highest severity of violation, typically reserved for situations where a nursing home’s failures place residents in serious harm or death.
Lab Results Ignored for Days
The resident had blood drawn on July 18, 2025. The results were so alarming that a facility physician later told inspectors the patient should have been transferred to a hospital immediately. Instead, no nurse or doctor reviewed those results before the resident died on July 22.
A second blood draw on July 21 showed deadly potassium levels, among other critical abnormalities. That report wasn’t reviewed until two days after the resident had already died.
The first set of results wasn’t reviewed until a full month after death.
CPR Order Ignored — Then Covered Up
The morning of July 22, a licensed practical nurse found the resident unresponsive with no pulse around 5:30 a.m. The resident had a medical order on file explicitly directing staff to attempt CPR if they had no pulse or stopped breathing.
The LPN decided against it anyway, later telling inspectors the patient appeared to have been dead for a while and that resuscitation would be “futile.” That call wasn’t hers to make — facilities are required to have a registered nurse on-site at all times, and the decision to withhold CPR should never have been left to an LPN acting alone.
What happened next made it worse. The facility’s director of nursing knew the incident had to be reported to the state. But the nursing director told inspectors that the administrator instructed her not to report it — and that corporate staff backed that decision. State inspectors issued a separate citation for the alleged cover-up.
“Those citations are atrocious,” said Richard Mollot, executive director of the Long Term Care Community Coalition. “In my view, they speak to an inability to perform even the most basic functions that a nursing home is supposed to provide.”
Other Residents Were Also Put at Risk
The same inspection uncovered failures involving two additional residents. One had lab results showing severe kidney dysfunction — but a doctor wasn’t notified until the next day. Another tested positive for a MRSA infection, and those results weren’t sent to a physician for two days.
Onondaga Center is owned by Centers Health Care, a company that has previously faced scrutiny from the New York State Attorney General’s Office over financial fraud and neglectful care. Following the September inspection, federal officials added the facility to the Special Focus Facility candidate list — a federal roster flagging some of the worst-performing nursing homes in the country.
The facility isn’t alone in the county. Van Duyn Center for Rehabilitation and Nursing in Onondaga Hill sits on an even worse list, as one of only three full Special Focus Facilities in New York State. Together with Bishop Rehabilitation and Nursing Center — which was recently removed from that worst-of-the-worst list — Onondaga Center, Van Duyn, and Bishop account for 35% of the county’s total nursing home capacity.
Onondaga Center remains open and is expected to face financial penalties. Stories like this one underscore why staffing gaps and their effect on resident safety have become a central focus for regulators and advocates alike.
