Below 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 Oak Hill Rehabilitation And Nursing Care Center during CMS and state inspections, most recent first.
The facility's main kitchen failed to meet professional standards for food safety and sanitation. Observations revealed dried food spills, soiled surfaces, and improper storage of food items, including raw eggs above milk and unlabeled pitchers. The kitchen floors and walls were heavily soiled, and the dish machine was clogged with debris. The Food Service Manager cited short staffing as a reason for inadequate cleaning, acknowledging that food should not be stored under wastewater lines and should be properly labeled.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in legionella management and laundry handling. Annual legionella testing was not conducted in 2024, and sampling in 2023 and 2025 was incomplete. The laundry room lacked proper separation for dirty and clean linens, risking cross-contamination. The Corporate RN Infection Preventionist acknowledged the issue, noting the presence of residents on enhanced barrier precautions.
The facility failed to provide a nourishing, palatable, well-balanced diet during two lunch meals. A resident's tray was incomplete, with items missing and food served at incorrect temperatures. Another resident's tray was missing a diet soda. Staff interviews revealed kitchen staffing shortages and issues with meal preparation and delivery, leading to non-compliance with facility policies on tray identification and food temperatures.
The facility failed to properly dispose of garbage, leading to potential pest harborage. Observations showed open dumpsters with garbage bags hanging out and debris around the property. The staff smoking area was also poorly maintained, with a tipped-over ashtray and garbage on the ground. The Director of Maintenance and Food Service Director acknowledged these issues, noting that garbage should not be left around as it could attract wildlife.
A resident was found with unauthorized medication at their bedside, highlighting a deficiency in medication management and supervision. Despite having an as-needed order for acetaminophen, the resident self-administered a different dosage without facility staff noticing. Interviews revealed staff were unaware of the medication, and the DON confirmed no residents were authorized to self-administer medications.
A facility failed to store medications securely and within the proper temperature range. The first-floor medication refrigerator was unlocked and accessible to various staff, containing temperature-sensitive medications. The refrigerator was also observed at 60 degrees Fahrenheit, outside the required range, with pooled liquid soaking medication boxes. The facility's policies on locking medication storage and maintaining temperature were not followed.
A facility failed to provide appropriate care for residents with feeding tubes, leading to unclear documentation and interrupted feeding schedules. One resident with severe cognitive impairment had no documented tube feeding administration for several days, and two residents experienced late feedings due to sharing two pumps among three residents. The lack of proper documentation and communication with medical providers and dietitians contributed to the deficiency.
A resident with severe cognitive impairment and dependent on tube feeding had their feeding tube dislodged. An LPN discovered the issue but failed to notify a medical provider or assess the resident, resulting in a delay in care. The resident did not receive necessary nutrition or medication until the tube was replaced the following day. The facility's policy to notify a medical provider was not followed.
Food Safety and Sanitation Deficiencies in Main Kitchen
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. During observations, it was noted that there were dried food spills in the cooler, and clean lunch trays were coated with dust, grease, and debris. The back wall of the 3-bay sink and the lower shelving and drawers were soiled with dried food debris, dust, and grease. The floors in the dish room and around the ice machine were heavily soiled with blackened grease and grime. Additionally, the ice cream freezer was encased in ice, and there was food and debris on the floor of the storage rooms. Some canned goods and paper cups were soiled by a red liquid, and there was unfinished drywall that was not smooth and easily cleanable. Further observations revealed that a flat of raw unpasteurized eggs was stored above a crate of milk, and there was an unlabeled pitcher in the cooler. The kitchen floors and walls were heavily soiled with food splatters, grease, and grime. The dish machine was soiled on the outside, and the floor drain beneath appeared clogged with food debris. The Food Service Manager acknowledged the issues, citing short staffing as a reason for inadequate cleaning. They admitted that the kitchen should be cleaned every shift, but they only had four kitchen staff. The manager also noted that food products and equipment should not be stored under wastewater lines, and all food should be properly labeled to prevent cross-contamination.
Deficiencies in Legionella Management and Laundry Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by deficiencies in their legionella management and laundry handling processes. The facility did not conduct an annual assessment for legionella in 2024, and the sampling conducted in 2023 and 2025 did not include all required sites as per the facility's water management plan. The Director of Maintenance and the Administrator were unable to provide documentation of legionella testing results for 2024, and the lab could not locate these results. This lack of testing and documentation indicates a failure to ensure the facility's water was safe from legionella contamination. Additionally, the facility's laundry room did not adhere to accepted standards for handling, storing, processing, and transporting linens and laundry. The laundry room had only one entry/exit, which did not allow for the separation of dirty and clean linens, leading to potential cross-contamination. Clean clothes were stored in a closet alongside bags of dirty resident clothing due to a lack of space and bins for dirty laundry. The Corporate RN Infection Preventionist acknowledged the issue, noting that the facility was aware of the inadequate setup, which was particularly concerning given the presence of residents on enhanced barrier precautions for multiple drug-resistant organisms.
Deficiencies in Meal Service and Dietary Compliance
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that met the daily nutritional needs of residents during two lunch meals observed on 3/17/2025 and 3/18/2025. On 3/17/2025, a resident's lunch tray was incomplete, missing items such as milk, water, butter, and dessert. The mixed fruit served was at an inappropriate temperature of 71.2 degrees Fahrenheit, and the bread was improperly placed on top of spinach and pasta, causing it to become soggy. Additionally, the meal ticket instructions were not followed, as the meat sauce was spread over the pasta instead of being placed on the side. On 3/18/2025, another resident's lunch tray was missing a diet soda, which was confirmed by the registered dietitian. Interviews with staff revealed that the kitchen was short-staffed, leading to issues with meal preparation and delivery. The dietary staff admitted to not having enough food items on hand, resulting in substitutions that did not match the meal tickets. The Food Service Manager acknowledged that complaints about the food were common, particularly regarding the repetitive menu. The kitchen staff attempted to check trays before they left the kitchen, but errors still occurred. The facility's policies on tray identification and food temperatures were not adhered to, contributing to the deficiencies observed during the survey.
Improper Garbage Disposal and Pest Harborage
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, leading to conditions that could attract and harbor pests. Observations during the survey revealed multiple piles of garbage and debris around various outbuildings, dumpsters, and shipping containers on the property. Garbage was found littering the tree line at the edge of the property, and there were piles of pallets and construction materials that served as potential pest harborage areas. The dumpsters were left open, with garbage bags hanging out and some bags left on the ground. The Director of Maintenance acknowledged the issues, explaining that a bag of garbage was accidentally left and became frozen to the ground, and the dumpster company repeatedly set the dumpster back on top of it, preventing its removal. Additionally, the staff smoking area was not maintained properly, with a smoking tower and metal ashtray found tipped over and a plastic bag of garbage spilled on the ground. The Director of Maintenance stated that staff smoked by the dumpsters, where an ashtray was provided but was being used for garbage and cigarette butts. Interviews with the Food Service Director and a Dietary Aide revealed a lack of awareness that the metal can in the smoking area was intended as an ashtray. The Food Service Director also noted that garbage should not be left around the building as it could attract wildlife, and they were aware of the debris around the dumpsters and other buildings, which were potential pest harborage areas.
Medication Mismanagement and Supervision Deficiency
Penalty
Summary
The facility failed to ensure a resident environment free from accident hazards, as evidenced by the presence of medication at the bedside of a resident without a medical provider's order and without evaluating the resident's ability to self-administer medications. Resident #40, who was cognitively intact and had diagnoses including chronic kidney disease and chronic pain, was observed with a bottle of acetaminophen 650 mg tablets at their bedside. The resident reported taking the medication a few times a week for left leg pain, despite having an as-needed order for acetaminophen 500 mg tablets every 8 hours for chronic pain, which was not administered according to the March 2025 medication administration record. Interviews with facility staff revealed a lack of awareness and adherence to the facility's medication storage policy. Certified Nurse Aide #7 and Licensed Practical Nurse #10 both stated that medications should not be in resident rooms due to safety concerns, yet neither noticed the medication at the resident's bedside. The Director of Nursing confirmed that no residents were authorized to self-administer medications and expected any medications found at a resident's bedside to be removed immediately, with the physician and Director of Nursing notified. This oversight in medication management and supervision contributed to the deficiency identified during the recertification survey.
Medication Storage Deficiency in Unlocked Refrigerator
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with professional principles, as observed during a recertification survey. Specifically, the medication refrigerator on the first floor was found unlocked and located in an accessible clean utility room, which was accessible to various staff members, including housekeeping, maintenance, therapy, and certified nurse aides. The refrigerator contained temperature-sensitive medications such as insulin pens, semiglutide injection pens, and tuberculin skin test vials. The facility's policy required that medication storage compartments be locked and accessible only to authorized personnel, but this was not adhered to. Additionally, the medication refrigerator was not maintained within the proper temperature range, as it was observed at 60 degrees Fahrenheit, which is outside the facility's policy range of 35 to 45 degrees Fahrenheit. This temperature discrepancy was noted on multiple occasions, and the refrigerator contained pooled clear liquid, which had soaked the medication boxes. Despite the facility's policy requiring maintenance to be called for inspection when temperatures are out of range, there was no indication that appropriate action was taken to address the temperature issue. The Director of Nursing was not notified about the unlocked refrigerator, and it was acknowledged that the refrigerator should have been locked and that all medications should be discarded and replaced due to the temperature issue.
Inadequate Tube Feeding Management in LTC Facility
Penalty
Summary
The facility failed to ensure that residents receiving enteral nutrition through feeding tubes were provided with appropriate treatment and services to prevent complications. Specifically, the documentation for three residents who were fed by enteral means was unclear regarding the duration and amount of feeding administered and received. For Resident #1, there was no documented evidence of tube feeding administration for several days, and the Medication and Treatment Administration Records lacked documentation of the start and stop times of the tube feedings. Additionally, the facility was sharing two feeding pumps among three residents, leading to interrupted feeding schedules and late administration. Resident #1 had severe cognitive impairment and was dependent on tube feeding for more than half of their caloric intake. The resident had a history of pulling out their feeding tube due to agitation, and there was no documentation of the tube feeding administration from 10/2/2024 to 10/9/2024. Observations showed discrepancies in the amount of formula infused and the lack of markings on the bottle to indicate disconnection times. The facility's staff did not notify the medical provider or registered dietitian about the interruptions in the feeding schedule. Residents #2 and #3 also experienced issues with their tube feeding schedules. Resident #2's feedings were administered late on multiple occasions, and there was no documentation of the scheduled feedings on certain days. Resident #3's feeding times conflicted with the availability of feeding pumps, and there was no evidence that the medical provider or dietitian was contacted to address the issue. The Director of Nursing was unaware of the pump-sharing situation and the resulting late feedings, which required notification of the medical provider. The lack of proper documentation and communication contributed to the deficiency in providing appropriate care for residents with feeding tubes.
Failure to Timely Address Dislodged Feeding Tube
Penalty
Summary
The facility failed to ensure that a resident received timely assessment and care following the dislodgement of their feeding tube. The resident, who had severe cognitive impairment and was dependent on tube feeding for more than half of their caloric intake, had their feeding tube dislodged. The incident was discovered by an LPN who noted the tube was out of place and the linens were saturated with feeding. Despite this, the LPN did not notify a medical provider or assess the resident, and the feeding was held until the tube could be replaced the following morning. The lack of immediate action resulted in the resident not receiving any medications, fluids, or nutrition after the tube was dislodged. The Director of Nursing was not informed until the next day, and the medical provider was not notified until hours after the incident. The facility's policy required that a medical provider be notified if a tube feeding was not administered as ordered, which was not followed in this case. The LPN responsible for the initial oversight resigned before formal discipline and education could be administered.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Beechtree Center For Rehabilitation And Nursing | 0.6 mi | ★★★★★ | 14 | 0 |
| Cayuga Nursing And Rehabilitation Center | 3 mi | ★★★★★ | 0 | 0 |
| Kendal At Ithaca | 3.3 mi | ★★★★★ | 0 | 0 |
| Groton Community Health Care Ctr Res Care Fac | 12.3 mi | ★★★★★ | 25 | 0 |
| Guthrie Cortland Medical Center | 19.7 mi | ★★★★★ | 14 | 2 |
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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.