Beacon Rehabilitation and Nursing Center

Based on observation, interview and record review, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, multiple refrigerated food items were undated and stored in open packaging. Additionally, the kitchen staff were not monitoring the cold food temperatures. The findings are: A facility policy titled Food Storage documented all food stored is maintained in a safe, sanitary, and temperature-controlled manner in order to prevent foodborne illnesses, contamination, and spoilage. All food items shall be stored, labeled, dated, and monitored in accordance with the accepted food safety standards and regulatory requirements. All refrigerated food items must be covered, labeled, dated, and discarded according to the facility's guidelines. All prepared, opened or thawed foods must be labeled with date prepared/opened. Unlabeled or expired food shall be discarded immediately. A facility policy titled Food Temperature Control and Food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interviews the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. This was identified for one (1) (Resident #70) of two (2) residents reviewed for Dignity. Specifically, on 01/12/2026 Certified Nursing Assistant #1 was observed in the hallway pulling Resident #70 backwards for approximately 100 feet while the resident was laying completely flat on a shower bed. At the time, there were other residents and staff in the hallway.The finding is:The facility's policy titled Resident Dignity, Respect, and Self-Determination, last reviewed 01/15/2025, documented the facility is committed to protecting and promoting each resident's right to dignity, respect, privacy, individuality, and self-determination. All residents shall receive care in a manner that supports their dignity, privacy, independence, and quality of life. All residents have a right to privacy in treatment,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews the facility did not ensure that each resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for two (2) (Resident #7 and Resident #10) of three (3) residents reviewed for Pressure Ulcers. Specifically, 1) during the wound care observation for Resident #7, Licensed Practical Nurse #1 did not cleanse all surfaces of the wound bed, including the part of the wound with undermining (a pocket or shelf beneath the surface of the skin extending beyond the visible opening, making it harder to heal and prone to infection). Additionally, the air mattress weight setting for Resident #7 was not consistent with the resident's weight. 2) Resident #10's air mattress weight setting was not consistent with the resident's weight and the facility staff was unfamiliar with the pump functions and settings.The findings are:The facility's policy titled Wound Care and Dressing Change,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during an abbreviated survey (NY00334677), the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, was reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident in 1 out of 3 residents sampled for abuse (Resident #1). Specifically, Resident #1 and Certified Nursing Assistant #1 reported to Nursing Supervisor #1 on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews during an abbreviated survey (NY00334677), the facility failed to protect residents from potential abuse while an investigation was in progress. This was evident in 1 out of 3 residents sampled for abuse (Resident #1). Specifically, Resident #1 and Certified Nursing Assistant #1 reported to Nursing Supervisor #1 on 02/28/24 at approximately 7:00 pm, that Certified Nursing Assistant #2 kicked Resident #1 in their scrotal area. Nursing Supervisor #1 instructed Certified Nursing Assistant #2 to leave Resident #1's unit and to return to their unit on the 3rd floor. Certified Nursing Assistant #2 was allowed to complete their resident care assignment until their shift ended at 11:00 pm on 08/28/24. Certified Nursing Assistant #2 was removed from the schedule on 02/29/24. This occurred when the Director of Nursing and Assistant Director of Nursing became aware of the allegation of abuse on 02/29/24. The findings are: The facility's Abuse Prevention Policy and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during the Recertification survey from 01/28/2024 to 02/02/2024, the facility did not ensure the resident's right to participate in the development and implementation of their person-centered plan of care. This was evident for 2 (Resident #83 and #4) of 26 total sampled residents. Specifically, 1) Resident #83 and their representative were not invited to their care plan meeting, and 2) Resident #4 was not invited to their care plan meeting. The findings are: The facility policy titled Comprehensive Care Plan dated 02/2023 documented the plan of care will be reviewed and revised quarterly, annually, with significant change of status and as needed to enhance the resident's ability to meet resident objectives. 1. Resident #83 had diagnoses of hypertension and obstructive uropathy. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #83 was moderately cognitively impaired, and the resident and family participated in the assessment. Social Service Note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during the recertification survey from 1/28/2024 to 2/2/2024, the facility did not ensure a resident, or their designated representative was provided with a Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage at the termination of Medicare Part A benefits. This was evident for 1 (Residents #62) of 3 residents reviewed for Beneficiary Notification out of 26 total sampled residents. Specifically, Resident #62 and their designated representative were not provided with a Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage once Resident #62 was terminated from skilled services and remained in the facility. The findings are: The facility policy titled Notice of Medicare Non-Coverage and Advance Beneficiary Notice of Non-coverage Benefits Exhaust Letter dated 1/2024 documented it is the policy of the facility to give a completed copy of notices to beneficiaries…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review conducted during the Recertification Survey from 1/28/2024 to 2/2/2024, the facility did not ensure a comprehensive person-centered care plan was reviewed and revised to address a resident's needs. This was evident for 2 (Resident #4 and Resident #98) of 26 total sampled residents. Specifically, 1) Resident #4's comprehensive care plans were not reviewed and revised to reflect Resident #4's diagnosis management and medication administration, and 2) Resident #98's comprehensive care plan was not reviewed and revised to reflect their risk for elopement. The findings are: The facility policy titled Comprehensive Care Plans dated 2/2023 documented the plan of care will be reviewed and revised quarterly, annually, with significant change of status and as needed to enhance the resident's ability to meet their objectives. 1) Resident #4 had diagnoses of right humerus fracture and atrial fibrillation. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey from 1/28/2024 to 2/2/2024, the facility did not ensure an ongoing activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident. This was evident for 1 (Residents #57) of 26 sampled total residents. Specifically, Resident #57 was not provided an activity program according to their interests and experienced cancellation of activities with no alternative and without resident notification. The findings are: The undated facility policy titled Therapeutic Recreation documented that the facility Recreation Therapist/Aide will provide each resident with daily choices, options, and program alternatives to spend their time and will maintains an attendance log for each activity to assess participation and socialization to ensure meaningful activities are being offered. Resident #57 had diagnoses of coronary artery disease and anemia. The Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification and Complaint survey (NY00297169) from 1/18/2024 to 2/2/2024, the facility did not ensure a resident received timely radiologic or other diagnostic services. This was evident for 1 (Resident #57) of 26 total sampled residents. Specifically, gynecology and vascular consults were not ordered and completed timely Resident #57 had delay in receiving medical management at consultation services. The findings are: The facility policy titled Consultations dated 2/5/2023 documented Licensed Practical Nurses will follow up all consultation orders as ordered and written by the physician for all resident's consultations. This includes any request for medical or clinical office visits. If there is a delay of more than 30 days before the consultant could examine the resident, the Registered Nurse Supervisor and the Medical Director will be notified. Resident #57 had diagnoses of deep vein thrombosis and coronary artery disease. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification Survey from 01/28/2024 through 02/02/2024, the facility did not ensure a resident's records were accurately documented. This was evident in 2 (Resident #61 and #67) of 26 total sampled residents. Specifically, 1) Licensed Practical Nurse #1 inaccurately documented Resident #61 was administered antianxiety medication, Xanax, and 2) Resident #67 was documented as having a Foley catheter after the Foley catheter had been removed. The findings are: The undated facility policy titled Medication Administration documented the nurse signs off on the Medication Administration Record immediately after administration of the medication. 1) Resident #61 had diagnoses of anxiety and bipolar disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #61 was cognitively intact. On 01/31/2024 at 12:06 PM, the North 4 medication cart was observed with Resident #61's 8 AM Xanax .25mg dose present on the cart. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and staff interviews conducted during the Recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, 1). oxygen tubing was observed touching the floor on multiple occasions, and 2). the facility-specific water management plan for Legionella was missing the following required components: (a) environmental assessment of water system. (b) Legionella sampling plan in place for the potable water system. This was evident for 2 out 2 residents reviewed for Respiratory Care out of a sample of 24 residents and during review of Infection Control. (Resident # 6 and Resident # 54) The findings are: 1 (a). Resident #6 was admitted to the facility with diagnoses that include Congestive Heart Failure and Pulmonary hypertension The Annual Minimum Data Set (MDS) dated [DATE], documented that resident's cognition was moderately impaired and that extensive assistance with 2 persons physical assistance was needed for transfers and toilet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews during the Recertification survey, the facility did not ensure individual resident financial records were made available to resident and resident representatives through quarterly statements. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter. This was evident for 2 of 2 residents reviewed for Personal Funds out of total sample of 24 residents sampled. (Residents #46 & #67) The findings are: The facility policy titled Resident Fund dated 10/1/2018, documented after each quarter or as requested, Quarterly statements will be distributed to all the residents with capacity accompanied by a signature confirming their receipt. For all other residents who lack capacity, the Quarterly statement will be emailed/mailed to their designated rep with a signature by the Finance Coordinator/designee. 1.Resident #46 was admitted to the facility on [DATE] with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews conducted during the Recertification survey, the facility did not ensure that needed services, care and equipment are provided to assure that resident with limited range of motion and mobility maintain or improve function based on the residents' clinical condition. Specifically, a resident was not provided with the handroll, and splint device ordered to improve resident's contractures. This was evident for 1 out of 2 residents reviewed for Limited ROM out of 24 residents sampled. (Resident #53) The findings are: The facility's policy titled Use of Assistive Devices dated 2/20/2018, last revised 10/20/2021 documented that the purpose of the policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity .If recommended but not utilized, if this is by resident's choice, must be documented in the Comprehensive Plan of care. Resident #53 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.