Rebekah Rehabilitation and Extended Care Center

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey conducted from 09/15/2026 to 09/23/2026, the facility did not ensure sufficient nursing staff was consistently provided to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. Specifically, 1). Residents and staff reported the facility was short staffed with Certified Nursing Assistants and Licensed Practical Nurses especially on weekends both days and nights, which resulted in delays in performing Activities of Daily Living and personal care. 2). The facility Payroll Based Journal for Quarter 4 (July -September 2025) also revealed excessively low weekend staffing, and 3). [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents remained free from physical restraints. This was evident for one (1) of two (2) (Resident #222) residents reviewed for Restraints out of 38 total sampled residents. Specifically, bed bolsters were used for Resident #222 without assessment, physician's order, and consent.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, to the New York State Department of Health. This was evident for one (1) (Resident # 180) of five (5) residents reviewed for Accidents out of 38 total sampled residents. Specifically, on 01/09/2026 at approximately 9:07 PM, Resident #180 was observed sitting on the floor in the hallway with a large hematoma (a collection of clotted blood outside of the blood vessel usually caused by trauma) with an open laceration on the temple and abrasion to the left elbow. There was no witness on how Resident #180 sustained the injury and the source of injury could not be explained by the resident.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to develop a person-centered comprehensive care plan to meet each resident's preferences and goals; and address the resident's medical, physical, mental and psychosocial needs. This was evident for one (1) (Resident #8) of one (1) resident reviewed for activities out of 38 total sampled residents. Specifically, Resident #8's care plan for recreational activities was not initiated when the resident was readmitted to the facility after hospitalization.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure notice of the availability of the survey results were posted in areas of the facility that are prominent and accessible to the residents and the public. Specifically, there were no posted notices throughout the five (5) resident floors of the facility about the availability of survey results.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the Minimum Data Set Assessments were electronically transmitted to the Centers of Medicare/Medicaid Services Data System within 14 days of completion. This was evident for nine (9) of 9 residents' (Residents #5, #15, #69, #124, #8, #180, #166, #155, #144) Minimum Data Set assessments. Specifically, these residents Minimum Data Set Assessments were not electronically transmitted within 14 days after the facility completed the resident's assessment.

Inspectors wroteBased on record review and interviews conducted during an Abbreviated Survey (Incident# 641690 and Incident # 641669), the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This was evident in three (3) out of nine (9) residents (Resident #7, #8, and #9) sampled. Specifically, 1) the facility Accident/Incident Report dated 03/01/2025 documented that Resident #7's family member reported to Licensed Practical Nurse on 03/01/2025 at 5:00 PM that two (2) Certified Nursing Assistants who were roughed with Resident #2 early in the morning. [...]

Inspectors wroteBased on record review and interviews conducted during the recertification and abbreviated (NY00322703) survey from 12/6/2023 to 12/13/2023, the facility did not ensure all alleged violations involving abuse were reported to the New York State Department of Health (NYSDOH) immediately or within 2 hours after the allegation was made. This was evident for 5 (Resident #37, #48, #52, #159, and #89) of 39 total sampled residents. Specifically, 1) Resident #37 had an unwitnessed fall with injury that was not reported to the NYSDOH, 2) Resident #159, #48, and #52 were involved in a resident to resident altercation that was not reported to the NYSDOH, and 3) Resident #89's allegation of abuse against a Certified Nursing Assistant (CNA) was not reported to the NYSDOH.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure that all allegations of abuse, including injuries of unknown origin, were thoroughly investigated. This was evident for 1 (Resident #146) of 39 total sampled residents. Specifically, there was no documented evidence an investigation was conducted for Resident #146 who sustained a left hip fracture.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure a comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #5) of 39 total sampled residents. Specifically, a CCP was not developed for Resident #5's antibiotic use.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated (NY00307221) survey from 12/6/2023 to 12/13/2023, the facility did not ensure the resident's comprehensive care plan (CCP) was reviewed and revised after each assessment and as needed. This was evident for 2 (Resident #187 and #63) of 39 total sampled residents. Specifically, 1) Resident #187's CCP related renal dysfunction and hemodialysis was not reviewed upon each assessment, and 2) Resident #63's CCP related to anticoagulant use was not revised to reflect a change in treatment.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure services provided met professional standards. Specifically, Licensed Practical Nurse (LPN) #6 and #7 did not notify the Medical Doctor (MD) when a Symbicort inhaler was not available to provide Resident #21 with medication in accordance with MD Order (MDO).

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure a resident with limited range of motion received treatment and services to maintain or improve mobility. This was evidenced by 1 (Resident #141) of 2 residents reviewed for mobility out of 39 total sampled residents. Specifically, Resident #141 did not have a right elbow splint (RES) applied in accordance with Medical Doctor Order (MDO).

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure an account of all controlled drugs was maintained and periodically reconciled. This was evident for 1 (Unit 5) of 5 units observed for Medication Storage. Specifically, Licensed Practical Nurse (LPN) #3 did not reconcile a narcotics supply count for Resident #357.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure a resident was free of significant medication error. This was evident for 1 (Resident # 21) of 39 total sampled residents and 1 of 25 observed medication administration opportunities. Specifically, Resident #21 did not receive their Symbicort inhaler per Medical Doctor Order (MDO).

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 12/06/2023 and 12/13/2023, the facility did not ensure laboratory services were obtained to meet the needs of a resident. This was evident for 1 (Resident #92) of 39 total sampled residents. Specifically, Resident #92 did not have Hemoglobin A1c (HbA1c) laboratory test performed every 3 months in accordance with Medical Doctor Order (MDO).

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification and abbreviated (NY00307221) survey from 12/6/2023 to 12/13/2023, the facility did not ensure a resident's designated representative (DR) was notified of changes in treatment. This was evident in 1 (Resident #63) of 39 total sampled residents. Specifically, Resident #63's DR was not notified when the resident's blood thinner medication was not administered in relation to subconjunctival hemorrhage.

Inspectors wroteBased on observation, record review and interviews during an abbreviated survey (Case # NY 00323131), the facility did not ensure a cognitive impaired resident's right to be free from physical abuse. This was evident in 1 of 4 residents sampled (Resident #1). Specifically, on 08/28/23 at 06:53 PM, the facility's camesurveillance ra recording showed a physical altercation in the nursing unit hallway between Resident #1 and Licensed Practical Nurse (LPN) #1. They were seen pushing each other back and forth. Resident #1 stumbled but did not fall. At 06: 53 PM, LPN #1 placed their right hand over Resident #1's right shoulder and their left hand under Resident #1's left side of the chest and pulled Resident #1 into a room that was not Resident #1's room. At 06:57 PM, Resident #1 exited the room and entered the hallway holding their right arm. [...]

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification and Abbreviated Complaint Survey (NY00273394 , NY 00268895), the facility did not ensure residents' Comprehensive Care Plans (CCP) were reviewed and revised by the interdisciplinary team after each assessment. Specifically, there was no documented evidence the CCP related to Falls was updated to accurately reflect residents who had multiple falls and subsequent injuries. This was evident for 3 of 3 residents reviewed for Falls. (Resident #151, #169 and #260).

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey and Complaint Investigation (NY00273394), the facility did not ensure that a resident's assessment was accurate. Specifically, (1) the Minimum Data Set (MDS) 3.0 assessment for Resident #97 inaccurately documented mechanical ventilator use; and, (2) The MDS 3.0 assessment for Resident #151 did not accurately reflect antipsychotic medication use or frequency of falls. This was evident for 2 of 37 residents in the sample.

Inspectors wroteBased on observation, record reviews, and interviews conducted during the Recertification Survey, the facility did not ensure that a resident maintained acceptable parameters of nutritional status. Specifically, the facility did not effectively address a resident's decreased intake and significant weight loss of 11.33% in one month. This was evident for 1 of 14 residents reviewed for Nutrition out of a total sample of 35 residents (Resident #203).

Inspectors wroteBased on observation, record review, and staff interview conducted during the Recertification survey, the facility did not ensure expired medications were identified and removed from the current medication supply for disposition. Specifically, expired insulin and supplements were observed in the medication carts. This was evident on 2 of 5 units reviewed for Medication Storage (Units 3 and 4).

Inspectors wroteBased on observations, record reviews, and staff interviews during the recertification survey, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) During medication pass, the Licensed Practical Nurse (LPN #3) did not perform hand hygiene, as well as not cleaning and disinfecting the Blood Pressure (B/P) Cuff in between residents. This was evident for 1 of 8 residents observed for Medication Administration Observation (Resident #116). 2) LPN #3 did not clean and disinfect the Blood Pressure Cuff in between residents (Resident #116 and 359).