Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beechtree Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Food storage, temperature monitoring, and sanitation practices were not followed in the kitchen and during tray service. Multiple cooler temperature logs were incomplete, a food cart temperature log was blank during meal delivery, and several food items in the cooler were unlabeled and undated. A dietary aide served meals without a beard restraint, a CNA touched their hair while handling tray items, the 3-bay sink was not used properly for sanitizing pots, and the ice machine had visible black residue.
During two observed lunch meals, food and drink were served at improper temperatures, with hot items below 135°F and cold items above 41°F. Several residents reported that the food was not palatable, describing it as cold, bland, dry, or tough. Staff interviews confirmed that food temperatures were not always maintained or recorded as required, leading to dissatisfaction among residents.
The facility did not have an infection prevention and control program in place, as observed by surveyors. This deficiency reflects the absence of systematic measures to prevent and control infections among residents and staff.
A resident with HTN, CAD, and PVD did not have BP monitored as ordered before receiving lisinopril. The care plan called for antihypertensive monitoring, but the MAR/TAR lacked consistent documented BP checks, and staff did not obtain manual readings when the resident refused the electronic cuff because it was painful. Interviews showed the resident wanted manual BP checks, while an LPN said they did not try a manual cuff and the RN and PA expected manual readings to be obtained.
Expired and improperly retained medications were found in the Unit 2 med cart during survey observation. Surveyors observed cyclopentolate ophthalmic solution and albuterol past expiration, along with opened eye drops that were beyond the manufacturer’s 28-day timeframe. An LPN stated expired meds should not remain in the cart, and the DON confirmed opened eye drops and other time-limited products should be discarded when the manufacturer’s timeframe expires.
Meal trays did not consistently match tray tickets for two residents whose tickets documented double portions. One resident with ESRD, DM, and malnutrition received only single portions of meat at observed meals despite meal tickets showing double portions, and kitchen staff acknowledged a portion-size error. Another resident with depression, morbid obesity, and DM received incomplete trays and only single portions despite tickets listing double portions and specific menu items. Staff interviews confirmed tray tickets were supposed to be checked against the food served, but the ordered portions and items were not consistently provided.
Food Storage, Temperature Monitoring, and Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the main kitchen and during meal service. During observation, multiple temperature logs for the walk-in cooler, walk-in freezer, cook's cooler, and dessert cooler were incomplete with numerous missing AM and PM entries across several dates. A food cart temperature log attached to the cart was blank during a dinner meal observation, and the dietary aide stated the temperatures were obtained only after the meal was over and the cart had returned to the main kitchen. Unlabeled and undated food items were found in storage areas. In the walk-in cooler, three cups containing unidentified substances were observed on a shelf without labels or dates. In the cook's cooler, cheese, fried eggs, and a meat product identified by staff as leftover pork chop from the previous day were also unlabeled and undated. Facility policy required foods to be labeled and dated, and staff acknowledged that items in the cook's cooler should have been labeled and dated. Food handling and sanitation practices were also not followed. A dietary aide with chin hair approximately two inches long served food without a beard restraint during meal observations, and a CNA scratched their head and played with their hair while handling beverages and desserts for resident trays. At the three-bay sink, the first compartment contained sudsy water, the second clear water, and the third was empty while pots were being sanitized with a sanitizer and water mixture for only 5 seconds because staff were trying to use up an almost empty bottle of sanitizer. The ice machine also had a black substance along the ridge where ice dropped into the basin.
Failure to Serve Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink were served at palatable, flavorful, and appetizing temperatures during two observed lunch meals. During meal observations, food items such as baked chicken breast, fried potatoes, pork cutlet, zucchini, and rice were served below the required hot holding temperature of 135 degrees Fahrenheit, with some items measured as low as 96 degrees Fahrenheit. Cold items such as applesauce, water, and milk were served at temperatures above the required 41 degrees Fahrenheit or below. Residents reported that the food was not palatable, with specific complaints about food being cold, bland, dry, and tough to chew. Interviews with staff revealed that food was cooked in the kitchen and held in hot holding boxes or refrigerators before being distributed to the units. Food service aides were responsible for measuring and recording food temperatures prior to serving, and were instructed to notify supervisors if temperatures were not within the required range. Despite these procedures, food was served at improper temperatures, and residents expressed dissatisfaction with the palatability and temperature of their meals. The facility's policy required hot foods to be maintained at 135 degrees Fahrenheit or greater and cold foods at 41 degrees Fahrenheit or below, but these standards were not consistently met during the survey period.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was observed and documented by surveyors, indicating a lack of systematic measures to address infection risks within the facility. No specific residents, staff, or incidents were detailed in the report, and there were no direct observations of infection events or outcomes related to this deficiency.
Failure to Monitor Blood Pressure Before Antihypertensive Administration
Penalty
Summary
Resident #113, who had diagnoses including coronary artery disease, peripheral vascular disease, and hypertension, was assessed as cognitively intact on the 8/7/2025 MDS. The resident’s comprehensive care plan identified hypertension and included interventions for antihypertensives as ordered, monitoring for side effects, monitoring for edema, and monitoring/documenting/reporting signs and symptoms of malignant hypertension. The August 2025 MAR showed lisinopril ordered at bedtime with parameters to hold if systolic blood pressure was less than 120 or heart rate was less than 60, but there was no documented evidence that blood pressure was obtained before lisinopril administration from 8/11/2025 through 8/26/2025. The MAR later no longer included a place to record blood pressure readings for lisinopril, and the treatment record showed vital signs once daily for hypertension beginning 8/16/2025, with the resident requesting manual blood pressure checks because the machine hurt their arm. On 8/23/2025 and 8/26/2025, progress notes documented that the resident refused the electronic blood pressure machine because it was painful, but there was no documented evidence that a manual cuff was used or that the blood pressure was obtained at the time lisinopril was given. During interview, the resident stated staff refused to obtain manual blood pressures and that their blood pressure had been running very high while medications were being adjusted. An LPN stated that when the resident refused the machine, they did not try a manual blood pressure and only offered the machine when working alone. An RN stated staff were expected to obtain a manual cuff if the resident refused the machine, and the PA stated daily blood pressures were ordered and manual readings were expected, but they were not aware staff were not obtaining them after refusals.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility did not ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, including the appropriate accessory and cautionary instructions and expiration dates when applicable, for one of three medication carts reviewed. During observation of the Unit 2 medication cart, surveyors found cyclopentolate ophthalmic solution with an expiration date of 8/2023, albuterol with an expiration date of 11/8/2024, and unspecified eye drops that had been opened on 7/7/2025 and labeled as good for 28 days. During interviews, an LPN stated expired medications should be discarded and not left in the medication cart, and that the eye drops opened on 7/7/2025 should have been discarded because they were only good for 28 days after opening. The DON stated that when insulin, nasal spray, or eye drops were opened, they should be discarded once the manufacturer's recommended timeframe expired, and that expired medications should be removed from the cart and returned to the pharmacy for disposal.
Meal trays did not match tray tickets or ordered double portions
Penalty
Summary
The facility did not ensure planned menus were followed for two residents who were supposed to receive double portions at meals. The survey findings showed that tray tickets, production sheets, and meal service did not consistently match, and residents did not always receive the portions or menu items listed on their meal tickets. Facility policies required tray tickets to be accurate and verified before service, and required resident preferences and dislikes to be honored and documented in the care plan. One resident had diagnoses including end stage renal disease, diabetes, and unspecified protein-calorie malnutrition. The resident’s MDS documented intact cognition, need for set-up or clean-up assistance with eating, a weight of 195 pounds, and no significant weight changes. The care plan addressed risk for altered nutritional status related to chronic kidney disease and hemodialysis, and physician orders included a regular diet, supplements on non-dialysis days, and instructions to support oral intake. The resident stated they were supposed to get double portions at meals, but during meal observations the tray ticket listed double portions of protein/meats while the tray contained only one baked chicken breast or one slice of oven roasted turkey. Staff interviews showed the food was plated according to meal tickets, but the kitchen prepared the turkey at the wrong portion size and supervisors did not verify the correct portion sizes were prepared. The second resident had diagnoses including depression, morbid obesity, and diabetes. The resident’s MDS documented intact cognition, independence with eating, a weight of 348 pounds, and a therapeutic diet. The care plan stated preferences would be honored and diet served as ordered, and physician orders included a regular consistency, low concentrated sweets, no added salt diet. During meal observations, the resident’s tray ticket documented double portions, but the resident received only one slice of turkey and one slice of cheese on a sandwich, and at another meal the tray was missing a tossed salad with dressing and pita with hummus. Staff interviews confirmed that meal tickets were supposed to be checked against the tray before service, that double portions should be provided when listed, and that the resident’s meal tickets documented double portions per preference.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ithaca
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Hill Rehabilitation And Nursing Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Cayuga Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Kendal At Ithaca | 3.1 mi | ★★★★★ | 0 | 0 |
| Groton Community Health Care Ctr Res Care Fac | 12.3 mi | ★★★★★ | 25 | 0 |
| Schuyler Hospital Inc And Long Term Care Unit | 19.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.