Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Kendal At Ithaca during CMS and state inspections, most recent first.
Two residents in an LTC facility were found to have deficiencies in their care plans during a survey. One resident, with respiratory issues, lacked a care plan for oxygen therapy despite physician orders. Another resident, with a history of falls, had inconsistencies in their fall prevention care plan, missing key interventions like a motion sensor alarm and low bed. Staff interviews revealed a lack of consistency in updating and communicating care plans, posing risks to resident safety.
A resident with a history of stroke and severe dysphagia was inadequately supervised and fed without a clear dietary order, leading to potential choking hazards. The facility failed to conduct a timely swallowing evaluation and provide specific dietary instructions, resulting in inconsistent feeding practices and increased risk of aspiration.
A resident with a physician order for as-needed oxygen was receiving continuous oxygen without an updated order. Despite the order specifying oxygen use to maintain saturation levels above 92%, the resident was observed on continuous oxygen, and staff interviews confirmed the order was not updated to reflect continuous use, potentially leading to unnecessary oxygen use.
A facility failed to obtain informed consent from a resident or their representative before installing bed rails, despite the resident's severe cognitive impairment and need for assistance with bed mobility. The facility's policy did not explicitly require informed consent, leading to inconsistent practices among staff. Interviews revealed that staff recognized the importance of consent but did not consistently obtain it, resulting in a deficiency during the survey.
A resident with dementia and severe agitation had a PRN order for lorazepam that was not reassessed every 14 days as required. The facility lacked a formal process for tracking and renewing PRN orders, leading to the continued use of the medication without proper evaluation.
The facility failed to serve food at appropriate temperatures, with a resident receiving a lunch tray containing a grilled salmon grain bowl and French fries that were not at palatable temperatures. The salmon was served at 52 degrees Fahrenheit, the rice medley at 60 degrees Fahrenheit, and the French fries at 65 degrees Fahrenheit, all outside the acceptable range. Residents had previously complained about cold and unappetizing food, and staff interviews confirmed a lack of adherence to proper food temperature protocols.
The facility failed to provide meals that met the dietary preferences and needs of three residents. A resident did not receive yogurt and a banana for lunch as specified on their meal ticket. Two residents were not offered desserts listed on their menus, despite staff being responsible for ensuring meal tickets matched the food served. Interviews revealed a lack of adherence to meal tickets and resident preferences.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to ensure the development and implementation of comprehensive person-centered care plans for two residents, leading to deficiencies identified during a recertification survey. Resident #7, who had diagnoses including respiratory syncytial virus, asthma, and pneumonia, did not have a care plan that included oxygen therapy despite having physician orders for oxygen use. The resident's care plan only documented interventions related to shortness of breath and other conditions but omitted the critical aspect of oxygen therapy, which was necessary for the resident's treatment. Resident #37, who had a history of dementia and falls, had inconsistencies in their fall prevention care plan. The care plan included the use of Dycem in the resident's chair but did not document the use of a motion sensor alarm or a low bed with a floor mattress, which were part of the interventions following multiple fall incidents. The care card and daily documentation tasks also lacked consistency, leading to potential gaps in the implementation of fall prevention measures. Observations revealed the absence of a motion detector and Dycem, which were supposed to be part of the resident's safety interventions. Interviews with facility staff, including registered nurses and the Director of Nursing, highlighted a lack of consistency and accuracy in updating and communicating care plans and interventions. The Unit Manager was responsible for updating care plans, but there was no process to ensure the accuracy of care cards and daily documentation tasks. This inconsistency in care planning and documentation posed a risk to resident safety, as staff might not have been fully informed of the necessary interventions to prevent falls and ensure proper oxygen therapy.
Inadequate Supervision and Dietary Management for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure adequate supervision and appropriate dietary management for Resident #146, who had a history of a stroke and was on comfort care measures. The resident was admitted with a 'nothing by mouth' order, which was later changed to 'diet as tolerated' without a clear consistency order. This lack of specificity led to the resident being fed various foods, including mashed potatoes and honey-thickened liquids, before a swallowing evaluation was conducted. The resident exhibited difficulty swallowing, such as pocketing food, which indicated the need for a more precise dietary plan. The facility's policies required a physician's order for diet consistency, but these were not followed. Staff, including nurses and certified nurse aides, were unsure of the appropriate diet for the resident, leading to inconsistent feeding practices. Observations showed the resident being fed with their head at an unsafe angle, increasing the risk of choking and aspiration. Interviews with staff revealed confusion and a lack of clear instructions regarding the resident's dietary needs, highlighting a breakdown in communication and adherence to protocols. The Speech Language Pathologist's evaluation confirmed the resident's severe dysphagia and recommended specific dietary precautions, which were not initially implemented. The facility's failure to conduct a timely swallowing evaluation and provide clear dietary orders compromised the resident's safety. The deficiency was further exacerbated by the absence of a meal ticket and incorrect documentation of the resident's dietary needs, leading to potential hazards during feeding.
Failure to Update Oxygen Order for Continuous Use
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who had a physician order for oxygen at 2-3 liters per minute via nasal cannula to maintain oxygen saturation levels above 92%. Despite the order specifying oxygen use as needed, the resident was observed receiving continuous oxygen, and their oxygen saturation levels were consistently documented between 92% and 98% while on oxygen. The facility's policy required a physician order for oxygen administration, including specifications for delivery method and liter flow, and any changes to the delivery method required a physician's order. Interviews with facility staff revealed that the resident had not been trialed off oxygen, and the continuous use of oxygen was not aligned with the as-needed order. The Registered Nurse and the Director of Nursing acknowledged that if a resident required continuous oxygen, the physician order should have been updated to reflect this need. The failure to update the physician order for continuous oxygen use could lead to unnecessary oxygen use, as the resident's order was for as-needed oxygen to maintain saturation levels above 92%.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to obtain informed consent from a resident or their representative before installing bed rails, which is a requirement according to their policy. The policy, revised in 2018, mandates that side rails or positioning bars can only be used after evaluating the resident's appropriateness, including obtaining a physician's order and incorporating the use into the care plan. However, the policy did not explicitly require obtaining informed consent. Resident #6, who had severe cognitive impairment and required substantial assistance with bed mobility, had bilateral bedside positioning bars installed without documented informed consent. The resident's care plan and physician's order included the use of these bars for mobility assistance, but there was no evidence that the risks and benefits were reviewed with the resident or their representative. Interviews with facility staff, including the Administrator, LPN, Director of Rehabilitation, Registered Nurse Manager, and Director of Nursing, revealed a lack of clarity and consistency regarding the necessity of obtaining informed consent for bed rails. The Administrator admitted to never having completed informed consents for enabler bars, believing they were not technically side rails. Other staff members acknowledged the importance of obtaining consent to ensure residents or their representatives were aware of the risks, but they did not consistently obtain signed consents. This oversight led to the deficiency identified during the recertification survey.
Failure to Reassess PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that as-needed (PRN) orders for psychotropic medications were limited to 14 days or had a prescribing provider order to extend beyond 14 days with documented rationale. Specifically, a resident with dementia and severe agitation had a physician order for lorazepam, an antianxiety medication, as needed for behavioral disturbances during showers. This order was not re-evaluated for continued use after 14 days, as required by the facility's policy and regulatory standards. The resident's medication administration records showed that lorazepam was administered on multiple occasions without evidence of reassessment or renewal of the order. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed a lack of a formal process for tracking and renewing PRN orders for psychotropic medications. Although interdisciplinary team meetings were held every 14 days, there was no documented evidence that the resident's PRN lorazepam order was reviewed or renewed as required. The staff acknowledged the importance of monitoring and renewing such orders to prevent unnecessary medication use and potential adverse effects, such as increased confusion and falls, but the necessary procedures were not followed in this case.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food and drink were served at palatable, attractive, and safe temperatures during a recertification survey. Specifically, on the [NAME] Unit, a lunch tray served on 12/18/2024 contained a grilled salmon grain bowl and French fries that were not at appropriate temperatures. The salmon was served at 52 degrees Fahrenheit, the rice medley at 60 degrees Fahrenheit, and the French fries at 65 degrees Fahrenheit, all of which were not within the acceptable temperature range for either hot or cold food items. Additionally, the food was described as dry, overcooked, and lacking seasoning, making it unpalatable. Interviews and observations revealed that residents had previously expressed concerns about the food being cold and not tasting good. A Health Care Dining Attendant confirmed that they had been trained on proper food temperatures but did not know if the food had been left out before serving. The Director of Dining and Nutritional Services explained that cold food plates were prepared in the main kitchen and should have been kept below 40 degrees Fahrenheit, while warm items like French fries should have been 140 degrees Fahrenheit or higher. The failure to maintain these standards was noted as a deficiency in the facility's food service practices.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the dietary preferences and needs of three residents during a recertification survey. Resident #8, who was cognitively intact and independent with eating, did not receive yogurt and a banana for lunch as specified on their meal ticket on multiple occasions. Despite the resident's expressed willingness to consume these items, they were consistently omitted from the meal tray. Resident #25, with moderately impaired cognition and independent eating abilities, was not offered the fresh fruit dessert listed on their meal menu. Observations revealed that the resident often left the dining area without receiving their dessert, and staff confirmed that the dessert was not provided as per the resident's selection. Similarly, Resident #37, who required set-up assistance for eating, was not offered the desserts specified on their meal tickets, such as a salted peanut butter bar and carrot cake, on consecutive days. Interviews with dining staff and nursing aides highlighted a lack of adherence to meal tickets and resident preferences. Staff were responsible for ensuring that meal tickets matched the food served, including desserts, but failed to do so. The Director of Dining and Nutritional Services emphasized that residents should receive all items on their meal tickets, including desserts, regardless of whether they were circled, indicating a systemic issue in meal service delivery.
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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) |
|---|---|---|---|---|
| Cayuga Nursing And Rehabilitation Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Beechtree Center For Rehabilitation And Nursing | 3.1 mi | ★★★★★ | 14 | 0 |
| Oak Hill Rehabilitation And Nursing Care Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Groton Community Health Care Ctr Res Care Fac | 9.3 mi | ★★★★★ | 25 | 0 |
| Northwoods Rehab And Nursing Center At Moravia | 16.6 mi | ★★★★★ | 14 | 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.