Inspection Reports for Beechtree Center For Rehabilitation & Nursing
NY, 14850
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
18.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
263% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: Aug 29, 2025
Visit Reason
Inspection revealed multiple standard health and life safety code deficiencies including food sanitation, infection control, medication labeling, quality of care, and life safety systems. No actual harm but potential for minor discomfort noted.
Findings
Inspection revealed multiple standard health and life safety code deficiencies including food sanitation, infection control, medication labeling, quality of care, and life safety systems. No actual harm but potential for minor discomfort noted.
Deficiencies (15)
Food procurement,store/prepare/serve-sanitary
Infection control
Infection prevention & control
Label/store drugs and biologicals
Menus meet resident nds/prep in adv/followed
Nutritive value/appear, palatable/prefer temp
Quality of care
Cooking facilities
Egress doors
Means of egress - general
Portable fire extinguishers
Sprinkler system - installation
Sprinkler system - maintenance and testing
Sprinkler system - out of service
Subsistence needs for staff and patients
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 29, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey from 8/24/2025 to 8/29/2025 to assess compliance with regulatory requirements related to food service and infection prevention and control.
Findings
The facility failed to ensure food was served at safe and appetizing temperatures during lunch meals on 8/25/2025 and 8/26/2025, affecting palatability for some residents. Additionally, the facility did not maintain an effective infection prevention and control program, as staff failed to wear required personal protective equipment when entering rooms of residents on contact precautions.
Deficiencies (2)
Food was not served at palatable and appetizing temperatures during lunch meals on 8/25/2025 and 8/26/2025, with some residents reporting food was cold or not palatable.
Staff did not wear personal protective equipment when entering rooms of residents on contact precautions, risking transmission of infections.
Report Facts
Food temperature: 96
Food temperature: 121
Food temperature: 123.6
Food temperature: 131
Food temperature: 114.8
Food temperature: 53
Food temperature: 43.3
Food temperature: 45
Survey dates: 6
Residents reviewed for infection control: 7
Residents affected by infection control deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aid #11 | Certified Nurse Aide | Entered Resident #8's room without PPE and placed meal tray |
| Certified Nurse Aid #18 | Certified Nurse Aide | Entered Resident #8's room without gown or gloves and delivered packages |
| Certified Nurse Aid #17 | Certified Nurse Aide | Observed contact precaution sign and explained PPE requirements |
| Certified Nurse Aid #19 | Certified Nurse Aide | Entered Resident #111's room without gown or gloves and checked resident |
| Registered Nurse #20 | Registered Nurse | Entered Resident #111's room without gown or gloves to deliver food |
| Food Service Aide #1 | Food Service Aide | Described food holding temperatures and temperature log procedures |
| Kitchen Supervisor #3 | Kitchen Supervisor | Described food cooking and holding procedures |
| Assistant Director of Nursing | Assistant Director of Nursing | Explained staff education and PPE requirements for contact precautions |
| Director of Nursing/Infection Preventionist | Director of Nursing/Infection Preventionist | Explained contact isolation procedures and rationale for PPE use |
| Registered Nurse #22 | Registered Nurse | Present during food temperature observation on 8/25/2025 |
| Certified Nurse Aide #11 | Certified Nurse Aide | Present during food temperature observation on 8/26/2025 |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Aug 29, 2025
Visit Reason
The recertification survey was conducted from 8/24/2025 to 8/29/2025 to assess compliance with professional standards of practice, care plans, infection control, medication management, food service, and other regulatory requirements at Beechtree Center for Rehabilitation and Nursing.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate treatment and care according to orders, improper medication labeling and storage, failure to follow planned menus and portion sizes, serving food at improper temperatures, inadequate food safety and sanitation practices, and failure to implement infection prevention and control protocols including improper use of personal protective equipment for residents on contact precautions.
Deficiencies (6)
Failure to ensure residents received treatment and care according to professional standards and care plans, specifically Resident #113 did not have blood pressure monitored as ordered.
Drugs and biologicals were not labeled in accordance with professional principles; expired multidose medications were found in Unit 2 medication cart.
Planned menus were not followed for Residents #3 and #8; double portions were not provided as ordered.
Food and drink were not palatable, attractive, or served at safe and appetizing temperatures during lunch meals on 8/25/2025 and 8/26/2025.
Food was not procured, stored, prepared, distributed, and served in accordance with professional standards; issues included unlabeled/undated food, missing temperature logs, unclean ice machine, improper sanitation of cookware, and staff not wearing beard restraints or proper hygiene.
Failure to provide and implement an infection prevention and control program; staff did not wear personal protective equipment when entering rooms of residents on contact precautions (Residents #8 and #111).
Report Facts
Survey dates: 6
Medication carts reviewed: 3
Residents reviewed for menu compliance: 2
Meals observed: 2
Missing temperature log dates: 20
Residents on contact precautions reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #5 | Named in blood pressure monitoring deficiency and medication cart observation | |
| Director of Nursing | Interviewed regarding medication disposal and infection prevention | |
| Certified Nurse Aide #13 | Observed serving meals with incorrect portion sizes | |
| Food Service Aide #12 | Interviewed about meal portion sizes and tray accuracy | |
| Kitchen Supervisor #3 | Interviewed about food temperature, sanitation, and food safety practices | |
| Certified Nurse Aide #11 | Observed serving food without proper PPE in infection control deficiency | |
| Certified Nurse Aide #18 | Observed entering isolation room without PPE | |
| Certified Nurse Aide #19 | Observed entering isolation room without PPE and interviewed about infection control knowledge | |
| Registered Nurse #6 | Interviewed about blood pressure monitoring | |
| Physician Assistant #7 | Interviewed about blood pressure orders and expectations | |
| Registered Dietitian #15 | Interviewed about menu and portion size compliance | |
| Assistant Director of Nursing | Interviewed about infection control education and PPE requirements |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 24
Date: Nov 17, 2023
Visit Reason
Complaint survey identified multiple standard health and life safety code deficiencies including ADL care, criminal history review, food sanitation, grievances, pest control, nutrition, resident rights, dental services, environment, smoking policies, and mental health services. All deficiencies were corrected by January 16, 2024.
Findings
Complaint survey identified multiple standard health and life safety code deficiencies including ADL care, criminal history review, food sanitation, grievances, pest control, nutrition, resident rights, dental services, environment, smoking policies, and mental health services. All deficiencies were corrected by January 16, 2024.
Deficiencies (24)
ADL care provided for dependent residents
Department criminal history review
Food procurement,store/prepare/serve-sanitary
Grievances
Maintains effective pest control program
Nutrition/hydration status maintenance
Nutritive value/appear, palatable/prefer temp
Quality of care
Resident rights/exercise of rights
Routine/emergency dental srvcs in snfs
Safe/clean/comfortable/homelike environment
Smoking policies
Treatment/srvcs mental/psychoscial concerns
Alcohol based hand rub dispenser (abhr)
Electrical equipment - power cords and extens
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Exit signage
Fire alarm system - testing and maintenance
Hazardous areas - enclosure
Portable space heaters
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Nov 17, 2023
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys from 11/13/2023 to 11/17/2023 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, safe and homelike environment, grievance resolution, assistance with activities of daily living, provision of treatment and care according to orders, nutritional status maintenance, dental care timeliness, and food palatability and temperature. Specific issues included soiled incontinence pads left in resident rooms, damaged facility infrastructure, unresolved resident grievances, inadequate personal hygiene assistance, missed medication doses, unclean and undated wound dressings, failure to use pressure ulcer prevention devices as ordered, unplanned weight loss without care plan updates, delayed dental services, and food served at improper temperatures with poor flavor.
Deficiencies (8)
Resident #33 had soiled incontinence pads left on their recliner, and Resident #91's wheelchair headrest cover was missing exposing foam.
Facility had damaged flooring, holes in bathroom walls, and leaking sinks without timely work orders.
Resident #31's grievance regarding a missing streaming device was not promptly resolved or reimbursed.
Residents #11 and #416 were not consistently assisted with personal hygiene and timely incontinence care.
Resident #4 missed multiple medication doses without documented physician notification; Resident #71 had an unclean, undated dressing without an order; Resident #91 was not provided heel pressure reducing booties as ordered.
Resident #49 experienced unplanned weight loss and care plan was not updated to reflect broken/lost dentures or diet consistency changes; meal tickets did not reflect diet changes.
Resident #49 did not receive timely dental services; dentures were missing since March 2023 but dental evaluation occurred only in June 2023.
Food served at lunch meals on 11/14/2023 and 11/15/2023 was not served at proper temperatures and was bland or salty.
Report Facts
Weight loss percentage: 3.4
Medication missed doses: 4
Food temperatures: 119
Food temperatures: 110
Food temperatures: 140
Food temperatures: 51
Food temperatures: 115
Food temperatures: 147
Food temperatures: 124
Food temperatures: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #25 | Certified Nurse Aide | Stated Resident #33 needed incontinence pad changed when soiled. |
| CNA #22 | Certified Nurse Aide | Assigned to Resident #33, did not notice soiled incontinence pad. |
| RN #23 | Registered Nurse | Stated CNAs responsible for ADL care and incontinence care every 2 hours for Resident #416. |
| RN Unit Manager #24 | Registered Nurse Unit Manager | Stated soiled linens should not remain in rooms; expected care plans to be carried out. |
| LPN #15 | Licensed Practical Nurse | Noted missing wheelchair headrest cover for Resident #91. |
| Director of Therapy | Director of Therapy | Stated wheelchair headrest covers should be in place to prevent foam exposure. |
| Director of Social Services | Director of Social Services | Discussed grievance process for Resident #31's missing streaming device. |
| Activities Director | Activities Director | Assisted Resident #31 with ordering streaming device; aware of missing item. |
| RN #37 | Registered Nurse | Discussed medication administration and ordering process. |
| LPN Unit Manager #14 | Licensed Practical Nurse Unit Manager | Discussed responsibility for resident equipment and dressing orders. |
| LPN #17 | Licensed Practical Nurse | Noted undated, unclean dressing with dried blood on Resident #71's finger. |
| RD #5 | Registered Dietitian | Reviewed Resident #49's weights and diet; unaware of weight loss. |
| RN Unit Manager #2 | Registered Nurse Unit Manager | Discussed Resident #49's missing dentures and dental care delays. |
| Dentist #7 | Dentist | Contracted dentist who evaluated Resident #49 starting June 2023. |
| DON | Director of Nursing | Discussed expectations for medication administration, dressing changes, resident equipment use, and dental care. |
| Food Service Director | Food Service Director | Discussed food temperature standards and complaints about food flavor and temperature. |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Nov 17, 2023
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys from 11/13/2023 to 11/17/2023 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including residents' rights to dignified existence, safe and homelike environment, grievance resolution, assistance with activities of daily living, appropriate treatment and care, nutritional status maintenance, dental care timeliness, food palatability and temperature, food service safety, and pest control. Specific deficiencies included soiled incontinence pads left in resident rooms, damaged facility areas without timely repair, unresolved resident grievances, inadequate personal hygiene assistance, missed medication doses, unaddressed weight loss and denture issues, food served at improper temperatures and lacking flavor, expired food in refrigerators, and presence of fruit flies on the second floor.
Deficiencies (10)
Residents #33 and #91 were not ensured the right to a dignified existence; Resident #33 had a soiled incontinence pad in recliner and Resident #91's wheelchair headrest cover was missing exposing foam.
Facility did not ensure a safe, clean, comfortable, and homelike environment; damaged flooring, hole in bathroom wall, and leaking sink were observed without timely work orders.
Resident #31's grievance regarding a missing streaming device was not promptly resolved or reimbursed.
Residents #11 and #416 were not provided adequate assistance with activities of daily living; Resident #11 was not assisted with shaving and Resident #416 was not provided timely incontinence care.
Residents #4, #71, and #91 did not receive treatment and care according to professional standards; Resident #4 missed medication doses without physician notification, Resident #71 had an undated and soiled dressing without an order, and Resident #91 was not provided heel pressure reducing booties as ordered.
Resident #49 had unplanned weight loss, broken and lost dentures, and diet consistency changes not reflected in care plan or meal tickets.
Resident #49 did not receive timely dental services; lower denture missing since March 2023 and first dental evaluation not until June 2023.
Food served was not palatable, flavorful, or at safe and appetizing temperatures during lunch meals on 11/14/2023 and 11/15/2023.
Expired and undated food items were found in Unit 1 and Unit 2 dining room refrigerators/freezers.
Fruit flies were present on the second floor nursing unit, indicating ineffective pest control.
Report Facts
Weight loss: 3.4
Medication missed doses: 4
Food temperatures: 119
Food temperatures: 110
Food temperatures: 115
Food temperatures: 124
Food temperatures: 51
Food temperatures: 37
Expired food date: Oct 11, 2023
Expired food date: Jul 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #25 | Certified Nurse Aide | Interviewed regarding soiled incontinence pad for Resident #33 and incontinence care for Resident #416. |
| RN #23 | Registered Nurse | Interviewed regarding responsibilities for ADL care and incontinence care for Resident #33 and Resident #416. |
| LPN #15 | Licensed Practical Nurse | Interviewed regarding missing wheelchair headrest cover for Resident #91. |
| Director of Therapy | Interviewed regarding wheelchair maintenance and headrest cover for Resident #91. | |
| Director of Social Services | Interviewed regarding grievance for missing streaming device for Resident #31. | |
| Activities Director | Interviewed regarding missing streaming device for Resident #31. | |
| RN #37 | Registered Nurse | Interviewed regarding medication administration and oversight. |
| LPN Unit Manager #14 | Licensed Practical Nurse Unit Manager | Interviewed regarding dressing order oversight for Resident #71 and equipment for Resident #91. |
| RN Unit Manager #2 | Registered Nurse Unit Manager | Interviewed regarding denture replacement delays for Resident #49. |
| Food Service Director | Interviewed regarding food temperatures and expired food in refrigerators. | |
| Maintenance Director | Interviewed regarding pest control and fruit fly sightings. | |
| Dentist #7 | Interviewed regarding dental care and denture replacement for Resident #49. | |
| Nurse Practitioner #10 | Interviewed regarding medication orders and weight loss for Resident #49. | |
| Director of Nursing | Interviewed regarding medication administration, dressing orders, denture replacement, and care plan oversight. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Jul 7, 2022
Visit Reason
Complaint survey found deficiencies in accident hazards, investigation of violations, smoking policies, and mental health services with one immediate jeopardy level 4 deficiency. All deficiencies were corrected by August 16, 2022.
Findings
Complaint survey found deficiencies in accident hazards, investigation of violations, smoking policies, and mental health services with one immediate jeopardy level 4 deficiency. All deficiencies were corrected by August 16, 2022.
Deficiencies (4)
Free of accident hazards/supervision/devices
Investigate/prevent/correct alleged violation
Smoking policies
Treatment/srvcs mental/psychoscial concerns
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 21, 2022
Visit Reason
Covid-19 survey identified a deficiency in reporting to the national health safety network with no actual harm noted.
Findings
Covid-19 survey identified a deficiency in reporting to the national health safety network with no actual harm noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Aug 9, 2021
Visit Reason
The survey was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory requirements, including residents' rights, nutritional status, and provision of appropriate diets and adaptive equipment.
Findings
The facility was found deficient in protecting residents' rights to refuse room transfers, maintaining residents' nutritional status, providing food in appropriate consistencies, and supplying proper adaptive eating equipment. Specifically, Resident #56 was moved without consent, Residents #34 and #56 experienced significant weight loss without timely reassessment or proper nutritional interventions, Resident #34 received regular consistency food instead of mechanical soft diet, and Resident #243 was not provided the recommended spouted cup.
Deficiencies (4)
Failure to protect residents' right to refuse some types of non-requested transfers within the nursing home (Resident #56).
Failure to maintain acceptable nutritional status for Residents #34 and #56, including significant weight loss, lack of timely reassessment, and failure to provide ordered nutritional supplements.
Failure to provide food prepared in a form designed to meet individual needs for Resident #34, who was ordered a mechanical soft diet but received regular consistency foods.
Failure to provide special eating equipment and utensils for Resident #243, who was not provided a spouted cup as recommended and lacked appropriate reassessment after changes in adaptive equipment.
Report Facts
Weight loss: 25.4
Weight loss: 22.6
Weight loss: 18.9
Weight loss: 19.2
Weight loss: 14.6
Weight loss: 10.2
Weight loss: 9
Weight loss: 7.5
Weight loss: 9.3
Weight loss: 16.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RD #18 | Registered Dietitian | Conducted nutrition assessments, documented weight loss, and communicated with facility staff remotely. |
| Director of Social Services | Involved in room transfer decisions and communication with resident's representative. | |
| Administrator | Discussed room changes with interdisciplinary team and resident's representative. | |
| SLP #1 | Speech Language Pathologist | Recommended diet consistencies and adaptive equipment for residents. |
| RN Manager #6 | Registered Nurse Manager | Provided information on weight monitoring and diet orders. |
| LPN #20 | Licensed Practical Nurse | Provided nutritional supplements to resident despite lack of order on MAR. |
| Food Service Director | Responsible for meal ticket accuracy and diet consistency changes. | |
| CNA #2 | Certified Nurse Aide | Reported resident's preference for different drinking cups. |
| LPN #5 | Licensed Practical Nurse | Changed resident's adaptive feeding equipment without notifying therapy staff. |
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