Inspection Reports for
Kendal at Ithaca
2230 North Triphammer Road, Ithaca, NY, 14850
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Dec 19, 2024
Visit Reason
The inspection was a recertification survey conducted from 12/16/2024 to 12/19/2024 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including incomplete and inconsistent care plans for residents, inadequate supervision to prevent accidents, improper respiratory care, lack of informed consent for bed rails, improper management of psychotropic medication orders, and failure to provide palatable and complete meals according to resident preferences and dietary needs.
Deficiencies (7)
F 0656: The facility failed to develop and implement comprehensive person-centered care plans for 2 residents, including missing oxygen therapy care plan and inconsistent fall prevention interventions.
F 0689: The facility did not ensure adequate supervision to prevent accidents for a resident on comfort care who was fed before swallowing evaluation and had unclear diet orders.
F 0695: The facility failed to provide respiratory care consistent with professional standards for a resident receiving continuous oxygen without a proper physician order.
F 0700: The facility did not obtain informed consent from a resident or representative prior to installing bilateral bed rails.
F 0758: The facility failed to limit as needed psychotropic medication orders to 14 days or document rationale for extension for a resident receiving lorazepam.
F 0804: The facility did not ensure food and drink were palatable, attractive, and served at safe temperatures; a grilled salmon grain bowl and French fries were cold and lacked taste.
F 0806: The facility failed to provide food that accommodated resident allergies, intolerances, and preferences; residents did not receive yogurt, banana, or desserts as specified on their menus.
Report Facts
Oxygen saturation levels: 92
Lorazepam doses: 5
Survey dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #4 | Registered Nurse | Interviewed regarding oxygen therapy and diet orders for residents #7 and #146 |
| Registered Nurse Unit Manager #6 | Registered Nurse Unit Manager | Responsible for care plans and bed rail assessments; interviewed about oxygen orders and care plan updates |
| Director of Nursing | Director of Nursing | Interviewed about care plan responsibilities, bed rail consents, and medication order renewals |
| Physician #23 | Physician | Provided diet orders and discussed feeding and swallowing evaluations for Resident #146 |
| Speech Language Pathologist #22 | Speech Language Pathologist | Conducted swallowing evaluation for Resident #146 |
| Registered Nurse Manager #6 | Registered Nurse Manager | Completed bed rail assessments and interviewed about consent process |
| Health Care Dining Attendant #8 | Health Care Dining Attendant | Interviewed about meal delivery and dessert provision for residents |
| Certified Nurse Aide #9 | Certified Nurse Aide | Interviewed about meal ticket accuracy and missed food items for Resident #8 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 14
Date: Dec 19, 2024
Visit Reason
Multiple standard health and life safety code deficiencies were cited, all corrected by early 2025.
Findings
Multiple standard health and life safety code deficiencies were cited, all corrected by early 2025.
Deficiencies (14)
Bedrails — Standard Health Inspection Citation
Develop/implement comprehensive care plan — Standard Health Inspection Citation
Free from unnec psychotropic meds/prn use — Standard Health Inspection Citation
Free of accident hazards/supervision/devices — Standard Health Inspection Citation
Nutritive value/appear, palatable/prefer temp — Standard Health Inspection Citation
Resident allergies, preferences, substitutes — Standard Health Inspection Citation
Respiratory/tracheostomy care and suctioning — Standard Health Inspection Citation
Cooking facilities — Standard Life Safety Code Citation
Corridor - doors — Standard Life Safety Code Citation
Electrical systems - essential electric syste — Standard Life Safety Code Citation
Exit signage — Standard Life Safety Code Citation
Illumination of means of egress — Standard Life Safety Code Citation
Portable space heaters — Standard Life Safety Code Citation
Sprinkler system - maintenance and testing — Standard Life Safety Code Citation
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 5, 2023
Visit Reason
The inspection was conducted as a recertification survey to evaluate compliance with regulatory requirements related to medication storage and infection prevention and control practices.
Findings
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, specifically an unlocked treatment cart was observed multiple times. Additionally, the facility failed to maintain proper infection prevention practices as a licensed practical nurse did not perform hand hygiene prior to and between medication administrations for two residents.
Deficiencies (2)
F 0761: The facility failed to store all drugs and biologicals in locked compartments; an unlocked treatment cart containing scissors and treatment supplies was observed unsupervised in a resident hallway multiple times.
F 0880: The facility failed to establish and maintain an infection prevention and control program; a licensed practical nurse did not perform hand hygiene prior to medication administration and between residents.
Report Facts
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Named in infection prevention deficiency for failure to perform hand hygiene | |
| Registered Nurse (RN) Unit Manager #4 | Provided information on treatment cart storage policy | |
| Director of Nursing (DON) | Provided information on treatment cart storage and infection control practices | |
| Registered Nurse (RN) Infection Preventionist/Staff Educator | Provided information on infection control education |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: May 5, 2023
Visit Reason
Several standard health and life safety code deficiencies were cited, all corrected by June 30, 2023.
Findings
Several standard health and life safety code deficiencies were cited, all corrected by June 30, 2023.
Deficiencies (7)
Infection prevention & control — Standard Health Inspection Citation
Label/store drugs and biologicals — Standard Health Inspection Citation
Responsibilities of providers; required notif — Standard Health Inspection Citation
Electrical systems - essential electric syste — Standard Life Safety Code Citation
Hazardous areas - enclosure — Standard Life Safety Code Citation
Illumination of means of egress — Standard Life Safety Code Citation
Means of egress - general — Standard Life Safety Code Citation
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 12, 2021
Visit Reason
Annual inspection survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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