Beechtree Center for Rehabilitation and Nursing

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00342762) surveys conducted 8/24/2025-8/29/2025 the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards in one (1) out of one (1) main kitchen and for two staff (Dietary Aide #1 and Certified Nurse Aide #4). Specifically, in the main kitchen food was not labelled and dated; refrigerator and freezer temperatures were not recorded; cookware was not sanitized appropriately; potentially hazardous food temperatures were not recorded; and the ice machine was unclean. Additionally, Dietary Aide #1 did not wear a beard restraint while preparing meal trays; and Certified Nurse Aide #4 scratched their head and played with their hair while serving food.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 8/24/2025-8/29/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of (2) two meals (lunch meals on 8/25/2025 and 8/26/2025) reviewed. Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 8/25/2025 and 8/26/2025. Additionally, Residents #3 and #8 stated the food was not palatable and Resident #34 stated the food was often cold.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/24/2025 - 8/29/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (1) of one (1) resident (Resident #113) reviewed. Specifically, Resident #113 did not have their blood pressure monitored as ordered.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/24/2025-8/29/2025, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for one (1) of three (3) medication carts (Unit 2 medication cart) reviewed. Specifically, the Unit 2 medication cart had expired multidose medications.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/24/2025-8/29/2025, the facility did not ensure planned menus were followed for two (2) of two (2) residents (Residents #3 and #8) reviewed. Specifically, Residents #3 and #8 did not receive double portions as planned.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00383732) surveys conducted 8/24/2025-8/29/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of seven (7) residents (Residents #8 and #111) reviewed. Specifically, staff did not wear personal protective equipment when entering Residents #8's and #111's rooms, who were on contact precautions.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00315978) surveys conducted 11/13/2023-11/17/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for three isolated areas (the shower room across from room [ROOM NUMBER], the bathroom in resident room [ROOM NUMBER], and the main kitchen dish machine room). Specifically, the floor in the shower room across from room [ROOM NUMBER] was damaged; the wall in resident room [ROOM NUMBER] bathroom had a hole in it; and a hand wash sink in the main kitchen dish machine room was leaking.

Inspectors wroteBased on observation and interview during the recertification and abbreviated (NY00315667) surveys conducted 11/13/2023-11/17/2023, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (11/14/2023 and 11/15/2023 lunch meals). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00315667 and NY00326467) surveys conducted 11/13/23-11/17/23, the facility did not ensure each resident had the right to a dignified existence for 2 of 5 residents (Residents #33 and #91) reviewed. Specifically, Resident #33 had an unclean incontinence pad in their recliner and Resident #91's wheelchair head rest cover was in disrepair with exposed foam.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00315667) surveys conducted 11/13/2023-11/17/2023, the facility did not ensure that prompt efforts were made to resolve grievances that residents may have for 1 of 3 residents (Resident #31) reviewed. Specifically, Resident #31 ordered a streaming device that was delivered to the facility, the resident did not receive the device, and the facility did not reimburse the resident for the missing item.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00315667, NY00315978, and NY00326467) surveys conducted 11/13/2023-11/17/2023, the facility did not ensure that residents who were unable to carry out activities of daily living (ADLs) were provided the necessary services to maintain good grooming and personal hygiene for 2 of 4 residents (Residents #11 and #416) reviewed. Specifically, Resident #11 was not assisted with shaving and Resident # 416 was not provided timely incontinence care.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00315667, NY00315978, and NY00326712) surveys conducted 11/13/2023-11/17/2023, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 3 of 16 residents (Residents #4, #71, and #91) reviewed. Specifically, Resident #4 did not receive medications as ordered; Resident #71 had a dressing applied to their left index finger without an order and the dressing was observed soiled; and Resident #91 did not have heel pressure reducing booties in place as planned.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00326712) surveys conducted 11/13/2023-11/17/2023, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 8 residents (Resident #49) reviewed. Specifically, Resident #49 had an unplanned weight loss and the resident's care plan was not updated to include the unplanned weight loss, broken and lost dentures, and the need for modified food consistency. Additionally, when the resident's diet consistency was changed to mechanical soft, the change was not reflected on the resident's meal ticket.

Inspectors wroteBased on observation, record review and interview during the recertification survey completed 11/13/2023-11/17/2023, and abbreviated survey (NY00326712) the facility did not ensure residents received dental services in a timely manner for 1 of 1 resident (Resident #49) reviewed. Specifically, the resident's lower denture was reported missing in March 2023 and the resident did not see the dentist for an evaluation until June 2023.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 11/13/2023-11/17/2023, the facility did not ensure storage, preparation, distribution, and service of food in accordance with professional standards for food service safety for 2 of 3 resident dining room refrigerators (Units 1 and 2). Specifically, Unit 1 and Unit 2 had expired and undated food in their dining room refrigerators/freezer.

Inspectors wroteBased on observation and interview during the recertification survey conducted 11/13/2023-11/17/2023, the facility did not maintain an effective pest control program so that the facility was free of pests for 1 of 3 nursing floors (second floor). Specifically, fruit flies were present on the the second floor.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 8/3/21-8/9/21, the facility did not ensure residents maintained acceptable parameters of nutritional status for 2 of 7 residents (Residents #34 and #56) reviewed. Specifically, Residents #34 and 56 had significant weight loss and was not reassessed timely by clinical nutrition staff; did not receive ordered nutritional supplements as planned, and was not weighed as ordered.

Inspectors wroteBased on record review and interviews during the recertification and abbreviated surveys (NY00264542) conducted [DATE]-[DATE], the facility did not ensure residents had the right to refuse room transfers for 1 of 1 residents (Resident #56) reviewed. Specifically, Resident #56's health care proxy (HCP) and representative declined a room transfer and the facility moved the resident to another room within the facility.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 8/3/21-8/9/21, the facility did not ensure each resident received food and drink prepared in a form to meet individual needs for 1 of 7 residents (Resident #34) reviewed. Specifically, Resident #34 was ordered to receive a mechanical soft diet and received regular consistency foods.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 8/3/21-8/9/21, the facility did not provide special eating equipment for residents who needed them and appropriate assistance to ensure the resident can use the assistive devices when consuming meals and snacks for 1 of 2 residents (Resident #243) reviewed. Specifically, Resident #243 was not provided a spouted cup at meals as recommended and when nursing changed the adaptive equipment provided to the resident there was no evidence therapy staff were notified so that a reassessment could be completed to determine the appropriate adaptive feeding equipment.