Bezalel Rehabilitation and Nursing Center

Inspectors wroteBased on record review and interviews the facility failed to ensure that they employed a qualified staff member to serve as the Director of Food and Nutrition. This was identified during the kitchen task. Specifically, the current Director of Food Service did not meet the minimum qualifications of being a certified dietary manager or similar national certification for food service management and safety. The finding is: A review of the Facility Assessment documented the services of a Registered Dietitian as part-time, three days per week. The facility appointed Employee #11 as the Food Service Director. During the initial tour of the kitchen on 03/18/2026 at 09:45 AM, Employee #11 stated that they were the Acting Food Service Director as the previous Food Service Director had resigned a few months earlier and they were just temporarily supervising the kitchen. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that each resident with pressure ulcers received care, consistent with professional standards of practice, promote healing, prevent infection, and prevent new ulcers from developing for three (Resident #34, #1, and #79) of three (3) residents reviewed for Pressure Ulcers. Specifically, 1) Resident #34 had an air mattress to help heal pressure ulcers. The resident weighed 201 pounds; however, the air mattress weight setting was set at 450 pounds; 2) Resident #1 utilized an air mattress due to pressure ulcer to the sacrum. The air mattress weight setting for Resident #1was not set consistent with the resident's actual weight. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure each resident received preadmission screening for individuals with a mental disorder and individuals with intellectual disability. This was identified for one (1) (Resident #21) of 23 residents reviewed for Preadmission Screening and Resident Review. Specifically, Resident #21 was admitted to the facility on [DATE] with an incomplete Preadmission Screening and Resident Review form. Items 22 through 26 of the Preadmission Screening and Resident Review form dated were not completed prior to admission. Response to Items 22 through 26 would determine if a Level II evaluation was required. [...]

Inspectors wroteBased on record review and interviews the facility failed to ensure that for each pharmacist medication regimen review, the Physician documented in the medical record that the identified irregularity has been reviewed, and what, if any, action has been taken to address it; and if there is to be no change in medication, the Physician documented regarding the rationale for not changing the medication. This was identified for one (1) (Resident #10) of five (5) residents reviewed for unnecessary medications. Specifically, a pharmacy medication regimen review for Resident #10 dated 01/29/2026 recommended changing the medication oxybutynin (treats overactive bladder) to a different medication that causes less side effects. The disagree box was checked on the medication regimen review form; [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 03/14/2024 to 03/21/2024, the facility did not ensure Minimum Data Set 3.0 assessments were transmitted within 14 days of completion. This was evident for 1 (Resident #88) of 2 residents reviewed for resident assessment out of 24 total sampled residents. Specifically, Resident #88's Minimum Data Set 3.0 assessments were not transmitted within 14 days of the completion date.

Inspectors wroteBased on record review and interviews conducted during an Abbreviated Survey (NY00309677 and NY00307950), the facility did not ensure that all alleged violations involving abuse and neglect,were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency. Additionally, the facility did not ensure that the results of all investigations were reported to the State Survey Agency within 5 working days of the incident. This was evident in 3 of 3 residents (Residents #1, #2, #3) sampled for abuse. Specifically, 1.) On 01/30/2023 at approximately 4:30 am, Resident #2 was observed kissing and inappropriately touching Resident #1. An initial report was made to the New York State Department of Health on 01/30/2023 at 3:12 pm. The facility did not submit a Follow-up Investigation Report within 5 working days of the incident. [...]

Inspectors wroteBased on staff interviews and record review during an Abbreviated Survey (NY00307950), the facility did not ensure each resident received adequate supervision to prevent elopement. This was evident in 1 of 3 residents (Resident #3) sampled for elopement. Specifically, on 01/01/2023, Resident #3, who was severely cognitively impaired and had a wander alert device in place, left the building undetected through the front door at 3:55 pm. Resident #3 was located by the Registered Nurse Supervisor on 01/01/2023 at approximately 8:13 pm with family members walking towards the emergency room in close proximity to the facility.

Inspectors wroteBased on observation and interview conducted during the Recertification survey, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. Specifically, 1) nutrition supplements/paper goods storage room was not maintained in a clean sanitary manner, and 2) staff did not change contaminated gloves after disposing garbage. This was observed during the Kitchen facility task.

Inspectors wroteBased on observations and interviews conducted during the Recertification survey conducted from 3/8/22 to 3/15/22, the facility did not ensure that garbage and refuse were disposed of properly. Specifically, garbage dumpsters located outside adjacent to the parking lot were observed to be uncovered, overflowing with garbage and the area surrounding was scattered with debris and trash. This was observed during the Kitchen task.

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification/Complaint survey, the facility did not ensure that infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, the facility did not have (1) a facility-specific water management plan for Legionella with mandatory components including but not limited to: a description of the facility's water distribution system; temperature profile of the water system; control measures and actions to be taken if control measures not met; or (2) a sampling plan for the potable water system. In addition, the facility (3) environmental risk assessment was not reviewed within the last year, as required. This was evident for the Water Management Plan review for Infection Control.

Inspectors wroteBased on record review and staff interview, during the Recertification survey conducted from 03/08/2022- 03/15/2022, the facility did not ensure that the Minimum Data Set (MDS) assessment(s) were electronically transmitted to the CMS (Centers of Medicare/Medicaid Services) Data System within 14 days after assessments were completed. This was evident for 11 of 29 residents reviewed for MDS Discrepancy. (Residents: #30, #3, #4, #15, #19, #14, # 24, #20, #22, #21, #25).

Inspectors wroteBased on record review and interviews conducted during the Recertification survey conducted from 3/08/2022 to 3/15/2022, the facility did not ensure, to the extent practicable, that residents/resident representatives participated in the development of a Comprehensive Care Plan (CCP). Specifically, cognitively intact residents were not afforded the opportunity to participate in the care plan meetings. This was evident for 2 of 3 residents reviewed for Care Plan out of a sample of 25 residents. (Resident #111 and #107)

Inspectors wroteBased on observations and staff interviews conducted during a Recertification survey from 03/08/2022 to 03/15/2022, the facility did not ensure that controlled drugs were stored appropriately in locked compartments. Specifically, 1) two blister packets containing controlled drugs were observed stored in the refrigerator in the medication room and were not double locked, and 2) one bottle of controlled substance was observed stored in a removable double locked box locked in the refrigerator. This was observed on 2 of 3 units during the Medication Storage Task. (Units 2 and 4)