Beach Gardens Rehabilitation and Nursing Center

Inspectors wroteBased on observation, record reviews, and interviews, conducted during a survey, the facility failed to ensure that a resident was free from physical abuse. This was evident for one (1) out of six (6) residents (Resident #1) sampled for abuse. Specifically, Resident #1 has history of aggressive behavior. On 03/16/2026 at approximately 10:15 AM while Resident #1 & 2 was standing in the lobby waiting on the elevator to go upstairs. Resident#1 was observed swinging left wheelchair armrest hitting Resident #2 twice before staff members intervened. Resident #1 was arrested by the Police and taken to the hospital. Resident #2 was also transferred to the hospital on [DATE] for evaluation. Resident #2 did not require any stitches. Resident #1 and Resident #2 returned to the facility on [DATE]. Resident #2 sustained a laceration to mid forehead and was transferred to hospital for treatment. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment to the residents. This was evident in three (3) (2nd, 3rd, and 4th Floors) of 4 units observed. Specifically, residents' closets were in disrepair; resident wheelchairs were dirty; feeding pumps and poles were observed with feeding stains; curtains had dirt; walls had missing paint; and floors were stained and dirty.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to report all alleged violations involving neglect, abuse, and/or including injuries of unknown source to the State Survey Agency. This was evident in two (2) (Residents #154 & #46) of five (5) residents reviewed for Abuse out of 35 total sampled residents. Specifically, 1.) on 07/09/2025, Resident #154 was observed with a black and blue discoloration on their right eye. The resident was cognitively impaired and could not explain how the injury occurred. There was no witness to how the resident sustained the injury. This incident was not reported to the New York State Department of Health. 2.) On 05/30/2025, Resident #46 had a fall occurrence and sustained laceration on the forehead and cut on the bridge of the nose while being provided care by Certified Nursing Assistant #3. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evident during the kitchen and food service observations. This was evident during the kitchen and food service observation. Specifically, 1.) Dietary staff were observed not properly wearing hair restraint while in the kitchen; 2.) Expired enteral feedings were stored on the unit and by the security area; and 3.) Cold sandwiches were not stored at a safe temperature.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was evident during environmental observation. Specifically, the visitor's waiting area by the security desk had a hole on the baseboard, had cobwebs, debris on top of the air-conditioning unit; staff bathrooms had a hole in the wall and black colored stain on the floor; and resident's bathroom was out of order.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure each resident received food that accommodated their allergies, intolerances, and preferences. This was evident in one (1) of 20 residents reviewed. Specifically, Resident #115 received lunch trays that included foods that did not accommodate their documented preferences and diet.

Inspectors wroteBased on observation, interviews, and record review conducted during an Abbreviated Survey (NY00374237), the facility failed to ensure that all alleged violations are thoroughly investigated in response to allegations of abuse, neglect, exploitation, or mistreatment, and that the results of all investigations are reported to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency. This was evident for one out of six residents (Resident #1) reviewed for abuse. Specifically, during an interview on 07/30/2025 at 11:30 AM, Licensed Practical Nurse #1 stated that on 03/01/2025 or 03/02/2025, Resident #1's family complained to them that Certified Nursing Assistant #1 was verbally rough with Resident #1. Licensed Practical Nurse #1 stated that they called and notified Registered Nurse Supervisor #2. [...]

Inspectors wroteBased on observation, interviews, and record review conducted during an Abbreviated Survey (NY00374494), the facility failed to ensure a resident's medical record contained complete nursing notes in accordance with professional standards of practice. This was evident in one out of six residents (Resident #2) reviewed for Abuse. Specifically, on 03/08/2025, at 2:30 PM, Resident #2 complained to Registered Nurse Supervisor #2 that Certified Nursing Assistant #2 had hit them on the arm. Registered Nurse Supervisor #1 performed a body assessment but did not document it in Resident #2's Electronic Medical Records. There were also no nursing notes in Resident #2's Electronic Medical Record addressing Resident #2's behavior witnessed by Licensed Practical Nurse #2.

Inspectors wroteBased on observation, interviews, and record reviews conducted during Abbreviated Survey (NY00351660), the facility failed to protect a resident from physical abuse by nursing home staff. This was evident in 1 out of 3 residents (Resident #1) sampled for abuse. Specifically, on 08/17/2024 at 3:25 PM, Certified Nursing Assistant #1 reported that they observed Dietary Worker #1, used their foot to push the wheel of Resident #1's wheelchair out of the elevator. Resident #1 slipped out of their wheelchair into a sitting position on the footrest of their (Resident #1) wheelchair and on to the floor. Resident #1 was assessed by Registered Nurse Supervisors #1 with no visible injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared in accordance with professional standards of food safety. Specifically, (1) staff were observed not performing hand hygiene during food preparation; (2) meat was observed thawing in a sink without cold running water; (3) bulk items were not dated with open and use by dates and containers/lids were not clean; (4) bulk thickening agent being used after the best used by date. This was evident for the Kitchen Observation.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 11/3/2021 to 11/10/021, the facility did not ensure that infection control practices and procedures were maintained to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, a Registered Dietitian, a Certified Nursing Assistant, a Licensed Practical Nurse, and a Lead Mechanic were observed entering COVID-19 positive residents' room without wearing full PPE including N-95, goggle/face shield, gloves, and gown for droplet and contact precautions. This was evident for 3 out of 3 residents reviewed for Infection Control Task (Residents # 314, 312, and 316).

Inspectors wroteBased on observations, staff interviews and record reviews conducted during the recertification survey, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented in a timely manner to address the residents' medical, physical, mental, and psychosocial needs. Specifically, (1) No CCP was developed and implemented to address a resident's use of Psychotropic medications; and (2) A care plan with measurable goals and interventions was not developed for a resident receiving total assistance with Activities of Daily Living (ADL) care. This was evident for 1 out of 5 residents observed for Unnecessary Meds, Psychotropic Meds (Resident #82) and 1 of 2 residents observed for ADL care (Resident #70), out of an investigative sample of 25 residents.