Beth Abraham Center for Rehabilitation and Nursing

Inspectors wroteNumber of residents sampled: 4Number of residents cited: 1Based on observations, record review, and staff interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan and the residents' choices. This was evident for one of four residents (Resident #457) reviewed for Hospitalization out of a sample of 44 residents. [...]

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 1/29/2024 to 2/5/2024, the facility did not ensure a surety bond was purchased to secure all resident personal funds deposited with the facility. This was evident for 371 residents with personal funds accounts out of a census of 443 residents. Specifically, the facility's surety bond for $1,000,000.00 was not enough to cover the total resident personal funds account balance of $1,356,104.59.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 1/29/2024 to 2/5/2024, the facility did not ensure that residents had the right to send and receive mail. This was evident for 11 (Resident #s 56, 263, 64, 30, 219, 165, 96, 155, 325, 201, 148, and 107) Resident Council participants out of 38 total sampled residents. Specifically, the facility did not have a procedure in place for residents to send and receive mail on Saturday.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 1/29/2024 to 2/5/2024, 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 5 (Residents #54, 83, 124, 276, and 295) of 5 residents reviewed for Activities out of 38 total sampled residents. Specifically, 1) there was no evidence Resident #54 was engaged in a meaningful activity program, 2) there was no evidence Resident #295 was engaged in a meaningful activity program, 3) there was no evidence Resident #124 was engaged in a meaningful activity program, 4) Resident #83 was not observed to be engaged in a meaningful activity program, and 5) Resident # 276 was not observed engaged in a meaningful activity program.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 1/29/2024 to 2/5/2024, the facility did not ensure garbage and refuse were disposed of properly. This was evident during kitchen observation. Specifically, the facility garbage compactor did not have a door or cover to prevent the harborage and feeding of pests.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 1/29/2024 to 2/5/2024, the facility did not ensure a resident, or their representative received their personal funds account statement on a quarterly basis. This was evident for 1 (Resident #55) of 38 total sampled residents. Specifically, there was no documented evidence Resident #55, or their representative was provided with a quarterly personal funds statement.

Inspectors wroteBased on record review and interviews conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure that residents' personal funds deposited with the facility were conveyed to the individuals or probate jurisdiction administering the residents' estate within 30 days of death or discharge from the facility. This was evident for 3 (Resident #685, #686, and #687) of 38 total sampled residents. Specifically, the facility did not convey the personal funds accounts for Resident #685, #686, and #687 to the probate jurisdiction administering the residents' estates within 30 days of expiration.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 1/29/2024 to 2/5/2024, facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after occurrence, to the New York State Department of Health, 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. This was evident for 1 (Resident #227) of 38 total sampled residents. Specifically, the facility did not report to the New York State Department of Health when Resident #227 had an unwitnessed incident resulting in a head laceration and left arm fracture.

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 1/29/2024 to 2/5/2024, the facility did not ensure the assessment accurately reflected the resident's status. This was evident for 2 (Resident #34 and #84) of 38 total sampled residents. Specifically, 1) Resident #34's Minimum Data Set 3.0 assessment did not document the resident's hemodialysis treatment, and 2) Resident #84's Minimum Data Set 3.0 assessment did not document the resident's discharge from hospice.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 1/29/2024 to 2/5/2024, the facility did not ensure that resident menus and dietary preferences were followed. This was evident for 2 (Resident #126 and Resident #340) of 38 total sampled residents. Specifically, 1) Resident #126 did not receive food items listed on their lunch meal ticket, and 2) Resident #340 did not receive preferred food items listed on their meal ticket during lunch.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 1/29/2024 to 2/5/2024, the facility did not ensure infection control practices and procedures were maintained. This was evident for 1 (Unit 5ZP) of 12 resident units. Specifically, Certified Nursing Assistant #5 did not perform hand hygiene after having resident contact during lunch.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that it electronically transmitted encoded, accurate and complete Minimum Data Set (MDS) data to the Center for Medicaid/Medicare Services (CMS). Specifically, a Discharge MDS was not transmitted within 14 days after the assessment was completed. This was evident for 1 of 1 resident reviewed for Resident Assessment. (Resident #1). The finding is: The facility policy titled Electronic Submission of MDS revised 8/2021 documented that all MDS assessments and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS in accordance with current regulations governing the transmission of MDS data. The policy also documented that discharge MDS assessments should be submitted by MDS completion date + 14 calendar days. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification survey, the facility did not ensure that a resident received a written summary of the baseline care plan (BCP). Specifically, the medical record did not contain evidence that the summary was given to the resident. This was evident for 1 of 8 residents reviewed for Care Planning (Resident #141)

Inspectors wroteBased on observations and interviews conducted during a Recertification survey, the facility did not ensure that it established and maintained 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. Specifically, a nurse was observed not practicing appropriate hand hygiene while performing bolus tube feedings. This was evident for 1 resident reviewed for the Dining Observation Task. (Resident #414).

Inspectors wroteBased on observations, record reviews and interviews, during the recertification survey, the facility did not ensure that garbage was properly disposed. Specifically, two garbage receptacles inside the kitchen were wheeled out of the kitchen to the compactor area with no lids. This was evident for observations conducted in the Kitchen during the Kitchen Facility Task.

Inspectors wroteBased on observation and interview conducted during the recertification survey, the facility did not ensure that staff maintained and infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help the development and transmission of communicable diseases and infections. Specifically, (1) A License Practical Nurse (LPN #4) was observed performing blood pressure monitoring for 3 residents without cleaning the blood pressure cuff between residents. (2) LPN #5 was observed administering eye drops to a resident without proper hand hygiene. (3) LPN #3 did not perform proper hand hygiene during a wound care observation. This was evident for 4 of 9 residents observed during Medication Administration (Resident #s 233, 33, 368, and 589) and 1 of 5 residents reviewed for Pressure Ulcer (Resident #221) out of a total sample of 38 residents.

Inspectors wroteBased on observation, record review and interview, conducted during the recertification survey, the facility did not ensure residents received proper treatment and assistive devices to maintain hearing abilities. Specifically, a resident was not assisted with obtaining hearing devices per the plan of care. This was evident for 1 resident reviewed for Communication-Sensory (Resident # 195). The finding is: The facility policy regarding Consultation and Diagnostic Testing, dated 03/2018, documented that the Physician will write an order for consultation or diagnostic testing, including the reason for testing. The policy also documented that the Unit Clerk, upon receipt of the request, will schedule the appointment. If the consultation requires prior insurance authorization, it will be obtained by clerk unit. [...]

Inspectors wroteBased on observation, record review, and staff interview, during the recertification survey, the facility did not ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM. Specifically, (1) a resident with a left-hand contracture was not provided with a splint device as per physician's order; (2) a resident that was status post hip fracture had a wedge abductor pillow and knee separator incorrectly applied and/or not applied. This was evident for 2 of 4 residents reviewed for Positioning and Mobility out of a total sample of 38 residents (Resident #207 and #353).

Inspectors wroteBased on observation, record review and staff interviews, during the recertification survey, the facility did not ensure that nurses aides are able to demonstrate competency in skills and techniques necessary to care for resident's needs as identified thru resident assessment and described in the plan of care. Specifically, Certified Nursing Assistants (CNAs) were provided with training on how to apply assistive devices and splints. This was evident for 2 of 4 residents reviewed for Positioning and Mobility out of a total sample of 38 residents (Resident #207 and #353).