Inspection Reports for
Oak Hill Rehabilitation and Nursing Care Center
602 Hudson St, Ithaca, NY, 14850
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Inspection Report — Mar 19, 2025
Complaint Investigation State
Date: Mar 19, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2023 to 2025 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 60 complaints about this facility; 10 led to on-site inspections. The facility received 109.0 complaints per 100 beds versus a statewide rate of 57.4. Five citations resulted from those complaints.
Findings
Across 6 inspections, 32 citations were issued including 14 standard health and 18 Life Safety Code citations. The facility had 60 complaints with 10 on-site inspections and 1 enforcement action recorded.
Citations (27)
Standard Health Citation — Dispose Garbage And Refuse Properly: Failed to properly dispose garbage and refuse.
Standard Health Citation — Food Procurement,store/prepare/serve-sanitary: Food procurement and preparation were not sanitary.
Standard Health Citation — Free Of Accident Hazards/supervision/devices: Facility was not free of accident hazards and lacked proper supervision.
Standard Health Citation — Infection Prevention & Control: Infection prevention and control measures were inadequate.
Standard Health Citation — Label/store Drugs And Biologicals: Failed to properly label and store drugs and biologicals.
Standard Health Citation — Other Laws, Codes, Rules And Regulations: Violated other applicable laws and regulations.
Standard Health Citation — Provided Diet Meets Needs Of Each Resident: Diet did not meet the needs of each resident.
Life Safety Code Citation — Building Rehabilitation: Building rehabilitation did not meet NFPA requirements.
Life Safety Code Citation — Cooking Facilities: Cooking facilities did not meet NFPA requirements.
Life Safety Code Citation — Electrical Equipment - Power Cords And Extens: Electrical equipment power cords and extensions were non-compliant.
Life Safety Code Citation — Electrical Systems - Essential Electric Syste: Essential electrical systems did not meet NFPA requirements.
Life Safety Code Citation — Fire Alarm System - Testing And Maintenance: Fire alarm system testing and maintenance were inadequate.
Life Safety Code Citation — Hazardous Areas - Enclosure: Hazardous areas were not properly enclosed.
Life Safety Code Citation — Illumination Of Means Of Egress: Illumination of means of egress was insufficient.
Life Safety Code Citation — Maintenance, Inspection & Testing - Doors: Doors were not properly maintained, inspected, or tested.
Life Safety Code Citation — Means Of Egress - General: Means of egress did not meet NFPA requirements.
Life Safety Code Citation — Portable Fire Extinguishers: Portable fire extinguishers were not compliant with NFPA standards.
Life Safety Code Citation — Smoking Regulations: Smoking regulations were not properly enforced.
Life Safety Code Citation — Sprinkler System - Maintenance And Testing: Sprinkler system maintenance and testing were inadequate.
Life Safety Code Citation — Stairways And Smokeproof Enclosures: Stairways and smokeproof enclosures did not meet NFPA requirements.
Life Safety Code Citation — Subdivision Of Building Spaces - Smoke Barrie: Building spaces subdivision and smoke barriers were non-compliant.
Life Safety Code Citation — Subsistence Needs For Staff And Patients: Subsistence needs for staff and patients were not adequately met.
Life Safety Code Citation — Utilities - Gas And Electric: Utilities for gas and electric did not meet NFPA requirements.
Standard Health Citation — Quality Of Care: Quality of care was deficient.
Standard Health Citation — Tube Feeding Mgmt/restore Eating Skills: Tube feeding management and restoration of eating skills were inadequate.
Standard Health Citation — Encoding/transmitting Resident Assessments: Resident assessments were not properly encoded or transmitted.
Standard Health Citation — Safe/clean/comfortable/homelike Environment: Environment was not safe, clean, comfortable, or homelike.
Report Facts
Inspections on page: 6
Total violations/deficiencies cited: 32
Inspections with violations: 5
Inspections without violations: 1
Plan of correction counts: Not explicitly stated
Total fines: 18000
Number of enforcement actions: 1
Total complaints: 60
On-site complaint inspections: 10
Complaint citations issued: 5
Inspection Report — Mar 19, 2025
Abbreviated Survey CMS
Date: Mar 19, 2025
Visit Reason
The visit was conducted as a recertification and abbreviated survey to assess compliance with nutritional and dietary regulations at the nursing facility.
Findings
The facility failed to provide residents with nourishing, palatable, well-balanced diets meeting their daily nutritional needs during two lunch meals observed on 3/17/2025 and 3/18/2025. Issues included food served at improper temperatures, missing meal items, unpalatable food textures, and failure to follow meal ticket directions.
Citations (1)
F 0800: The facility did not provide residents with nourishing, palatable, well-balanced diets meeting daily nutritional needs for two lunch meals. Food items were missing, cold dessert was served above the required temperature, and meal ticket directions were not followed.
Report Facts
Temperature of mixed fruit: 71.2
Temperature of mixed fruit: 71
Number of residents ordering chicken: 3
Number of residents ordering fish: 9
Missing water on tray: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #13 | Certified Nurse Aide | Verified meal tray issues and commented on resident complaints about food |
| Registered Dietitian #15 | Registered Dietitian | Verified missing diet soda on Resident #44's tray |
| Dietary [NAME] #14 | Dietary Staff | Reported kitchen staffing shortages and food supply issues |
| Food Service Manager | Food Service Manager | Discussed complaints about food, menu rotation, and kitchen staffing shortages |
Inspection Report — Mar 19, 2025
Annual Inspection CMS
Date: Mar 19, 2025
Visit Reason
The inspection was a recertification survey conducted from March 17 to March 19, 2025, to assess compliance with regulatory requirements for Oak Hill Rehabilitation and Nursing Care Center.
Findings
The facility was found deficient in multiple areas including medication storage and administration, food service safety and quality, infection prevention and control, laundry procedures, and proper disposal of garbage. Specific issues included unsecured medications, improper food temperatures and missing meal items, unsanitary kitchen conditions, lack of legionella testing in 2024, and inadequate separation of clean and dirty laundry.
Citations (6)
F 0689: The facility did not ensure the resident environment was free of accident hazards; Resident #40 had medication at bedside not ordered and was not evaluated for self-administration ability.
F 0761: The facility did not ensure drugs and biologicals were stored securely and at proper temperatures; the first-floor medication refrigerator was unlocked, accessible to all staff, and out of temperature range at 60 degrees Fahrenheit.
F 0800: The facility did not provide residents with nourishing, palatable, well-balanced diets meeting nutritional needs; observed meals had cold desserts served above proper temperature, missing items, and unpalatable textures.
F 0812: The facility did not ensure food was stored, prepared, distributed, and served according to professional standards; kitchen and storage areas were unclean with food spills, grease, grime, unlabeled items, and food stored under wastewater lines.
F 0814: The facility did not properly dispose of garbage and refuse; multiple piles of garbage and debris were observed around dumpsters and outbuildings, dumpsters were left open, and smoking areas were untidy.
F 0880: The facility failed to maintain an infection prevention and control program; legionella testing was not conducted in 2024 as required, and the laundry room lacked separate entry/exit for clean and dirty linens, risking cross-contamination.
Report Facts
Temperature of medication refrigerator: 60
Temperature of mixed fruit dessert: 71.2
Number of washing machines: 3
Number of dryers: 2
Number of bags of resident personal clothing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #7 | Interviewed regarding medication storage and clean utility room access. | |
| Licensed Practical Nurse #10 | Interviewed regarding resident self-administration of medications. | |
| Director of Nursing | Interviewed regarding medication policies and refrigerator security. | |
| Certified Nurse Aide #8 | Interviewed regarding storage of resident care items and medication refrigerator. | |
| Licensed Practical Nurse #9 | Interviewed regarding medication refrigerator temperature and security. | |
| Food Service Manager | Interviewed regarding food service deficiencies, kitchen staffing, and cleaning. | |
| Certified Nurse Aide #13 | Interviewed regarding resident meal tray observations. | |
| Registered Dietitian #15 | Verified missing diet soda on resident meal tray. | |
| Dietary #14 | Interviewed regarding kitchen staffing and food shortages. | |
| Food Service Director | Interviewed regarding garbage disposal and kitchen cleanliness. | |
| Dietary Aide #17 | Interviewed regarding smoking area ashtray. | |
| Director of Maintenance | Interviewed regarding medication refrigerator security, legionella testing, and garbage disposal. | |
| Laundry Aide #4 | Interviewed regarding laundry room procedures and separation of clean and dirty laundry. | |
| Corporate Registered Nurse Infection Preventionist | Interviewed regarding laundry room infection control and legionella testing. | |
| Administrator | Interviewed regarding legionella testing results and facility compliance. |
Inspection Report — Oct 25, 2024
Abbreviated Survey CMS
Date: Oct 25, 2024
Visit Reason
The abbreviated survey was conducted to assess compliance with professional standards of care related to treatment and care of residents receiving tube feedings.
Findings
The facility failed to ensure residents with feeding tubes received appropriate treatment and care, including timely assessment after tube dislodgement and proper documentation of tube feeding administration. Feeding pumps were shared among residents causing interrupted or late feedings, and medical providers were not consistently notified of feeding interruptions or changes.
Citations (2)
F 0684: The facility did not ensure Resident #1 was assessed timely by a qualified professional after their feeding tube became dislodged, and the medical provider was not notified as required.
F 0693: The facility failed to provide appropriate care for residents with feeding tubes by not ensuring timely and accurate documentation of tube feeding administration, sharing feeding pumps among residents causing late or interrupted feedings, and failing to notify medical providers of feeding interruptions or late feedings.
Report Facts
Residents affected: 3
Late tube feeding administrations: 21
Tube feeding rate: 80
Tube feeding volume: 360
Tube feeding volume: 420
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in finding for failure to notify medical provider and timely assessment after feeding tube dislodgement. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Notified medical provider and family about feeding tube dislodgement; provided clarifications on feeding schedules. |
| Director of Nursing | Director of Nursing | Provided interviews about notification procedures and facility practices; noted failure to notify medical provider and lack of feeding pump availability. |
| Registered Dietitian #5 | Registered Dietitian | Provided input on feeding schedules and expectations for feeding interruptions. |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Involved in feeding administration and interviews regarding feeding pump usage and documentation. |
Inspection Report — Mar 8, 2024
Abbreviated Survey CMS
Date: Mar 8, 2024
Visit Reason
The abbreviated survey was conducted to assess compliance with food service professional standards in the facility's kitchen.
Findings
The facility failed to properly store, prepare, distribute, and serve food according to professional standards. Issues included improperly heated food, uncovered food products, and numerous unclean and uncleanable surfaces in food service and storage areas.
Citations (4)
F 0812: The facility failed to properly heat food; stuffed shells were served at temperatures as low as 76-77 degrees Fahrenheit, below the required 140 degrees Fahrenheit.
F 0812: Food products were left uncovered in the kitchen, including a 1-gallon vegetable oil jug without a lid, an open can of mashed potatoes, and an open packet of beef soup mix.
F 0812: Numerous food service areas and equipment were unclean or uncleanable, including soiled refrigerators, prep tables, dish room walls, mechanical dishwasher, and kitchen hood filters.
F 0812: Staff failed to change gloves when handling raw meat and then touching clean utensils, risking cross contamination.
Report Facts
Temperature measurement: 76
Temperature measurement: 77
Temperature measurement: 140
Date of observations: Jan 29, 2024
Inspection Report — Jan 12, 2024
Abbreviated Survey CMS
Date: Jan 12, 2024
Visit Reason
The abbreviated survey was conducted to evaluate compliance with professional standards of care related to treatment and medication administration for residents, specifically focusing on Resident #2's care following hospitalization for septic shock.
Findings
The facility failed to ensure Resident #2 received prescribed preventative antibiotics and follow-up urology care as ordered. The resident did not receive nitrofurantoin suppressive therapy after completing Bactrim, and missed scheduled urology appointments without documented rationale, contributing to subsequent sepsis and hospitalization.
Citations (1)
F 0684: The facility did not provide appropriate treatment and care according to orders for Resident #2, who was admitted with septic shock and required preventative antibiotics and urology follow-up. There was no documented evidence that nitrofurantoin suppressive therapy was ordered or administered, and the resident missed scheduled urology appointments without explanation.
Report Facts
Residents Affected: 3
Residents Affected: Few
Inspection Report — Sep 28, 2023
Annual Inspection CMS
Date: Sep 28, 2023
Visit Reason
The survey was a recertification survey conducted from 9/25/2023 to 9/28/2023 to assess compliance with regulatory requirements for Oak Hill Rehabilitation and Nursing Care Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, timely transmission of Minimum Data Set (MDS) assessments, infection prevention and control practices, and proper use of call bells and staff cell phone policies. Deficiencies included unclean elevator access doors, inaccessible call bells, strong urine odors, staff cell phone use in resident care areas, late MDS submissions, and failure to follow enhanced barrier precautions for infection control.
Citations (3)
F 0584: Elevator #1 access door and walls were unclean with brown sticky debris and scraped paint. Call bells were not within reach in multiple resident rooms, and a strong urine odor was present near the first floor elevator and in resident bathrooms. Staff used personal cell phones near residents in violation of policy.
F 0640: The facility failed to transmit Minimum Data Set (MDS) assessments to CMS within 14 days of completion for 5 residents, resulting in late submissions documented by warning messages.
F 0880: The facility did not establish and maintain an infection prevention and control program. Staff failed to wear required personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions, risking transmission of infections.
Report Facts
Residents with late MDS assessments: 5
Dates of survey: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Infection Preventionist #9 | Registered Nurse Infection Preventionist | Observed using personal cell phone during resident care and not following enhanced barrier precautions. |
| Maintenance Director | Interviewed regarding cleaning and maintenance of elevator and facility environment. | |
| Director of Nursing | Director of Nursing | Interviewed regarding cell phone use policy enforcement and infection control. |
| MDS Coordinator | Interviewed regarding MDS assessment submission process and timelines. | |
| CNA #1 | Certified Nurse Aide | Observed not wearing gown during care of resident on enhanced barrier precautions. |
| CNA #3 | Certified Nurse Aide | Observed not wearing gown during care of resident on enhanced barrier precautions. |
| CNA #11 | Certified Nurse Aide | Observed not wearing gown during care of resident on enhanced barrier precautions. |
| LPN #2 | Licensed Practical Nurse | Instructed staff to wear gown during care of resident with open wound. |
| LPN #14 | Licensed Practical Nurse | Documented dressing change with copious drainage on resident's wound. |
Inspection Report — Jul 1, 2021
Abbreviated Survey CMS
Date: Jul 1, 2021
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with food safety and service standards at the nursing facility.
Findings
The facility failed to ensure food and drink were served at safe and appetizing temperatures, with multiple meal trays tested below required temperatures. Additionally, food service equipment such as the #10 can opener and exhaust hood were found unclean and soiled, indicating lapses in food safety and sanitation standards.
Citations (2)
F 0804: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Food trays served had temperatures below safe levels, including milk temperatures above 40°F and hot foods below 140°F during meal service.
F 0812: Procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards. The #10 can opener was unclean and sticky with food debris and rust, and the exhaust hood over the stove was dust and grease laden.
Report Facts
Meal tray temperatures: 3
Milk temperature: 58
Milk temperature: 77
Food temperature: 129
Food temperature: 135
Food temperature: 128
Food temperature: 181
Food temperature: 184
Food temperature: 198
Food temperature: 180
Food temperature: 198
Milk temperature: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Director | Interviewed regarding food temperature control and cleaning of kitchen equipment |
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