Beacon Rehabilitation and Nursing Center

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00334677), the facility failed to protect a resident from physical abuse by nursing home staff. This was evident in 1 out of 3 residents sampled for abuse (Resident #1). Specifically, on 02/28/24 at approximately 7:00 pm, Resident #1 reported to Nursing Supervisor #1 that they were kicked in the scrotal area by Certified Nursing Assistant #2. Resident #1 reported that when they were kicked in the groin, they screamed out in pain. Certified Nursing Assistant #1 also reported to Nursing Supervisor #1 they witnessed Certified Nursing Assistant #2 kick Resident #1 in their private area and that Resident #1 screamed out in pain. A nursing note, by Nursing Supervisor #1, dated 02/28/24 at 6:33 pm documented that a head-to-toe assessment was done immediately and revealed no visible injuries. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased 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)