Inspection Reports for
Beechtree Center For Rehabilitation & Nursing
NY, 14850
Back to Facility Profile4 Reports
Inspection Report — Aug 29, 2025
State
Date: Aug 29, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2022 to 2025 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 83 complaints about this facility; 12 led to on-site inspections.
Findings
Across 4 inspections, 54 citations were issued including 22 standard health and 32 Life Safety Code citations. The facility had 83 complaints with 12 on-site inspections and 3 enforcement actions totaling $30,000 in fines.
Citations (41)
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve-sanitary was cited for deficiencies.
Standard Health Citation — quality of care: Infection Control deficiencies noted.
Standard Health Citation — quality of care: Infection Prevention & Control deficiencies found.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals deficiencies identified.
Standard Health Citation — quality of care: Menus Meet Resident Needs/prep In Advance/followed deficiencies noted.
Standard Health Citation — quality of care: Nutritive Value/appearance, Palatable/preferred Temperature issues found.
Standard Health Citation — quality of care: Quality Of Care deficiencies cited.
Life Safety Code Citation — NFPA requirements: Cooking Facilities deficiencies noted.
Life Safety Code Citation — NFPA requirements: Egress Doors deficiencies found.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General deficiencies cited.
Life Safety Code Citation — NFPA requirements: Portable Fire Extinguishers deficiencies noted.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation deficiencies found.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficiencies cited.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Out Of Service deficiencies noted.
Life Safety Code Citation — NFPA requirements: Subsistence Needs For Staff And Patients deficiencies found.
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents deficiencies cited.
Standard Health Citation — quality of care: Department Criminal History Review deficiencies noted.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve-sanitary deficiencies found.
Standard Health Citation — quality of care: Grievances deficiencies cited.
Standard Health Citation — quality of care: Maintains Effective Pest Control Program deficiencies noted.
Standard Health Citation — quality of care: Nutrition/hydration Status Maintenance deficiencies found.
Standard Health Citation — quality of care: Nutritive Value/appearance, Palatable/preferred Temperature deficiencies cited.
Standard Health Citation — quality of care: Quality Of Care deficiencies noted.
Standard Health Citation — quality of care: Resident Rights/exercise Of Rights deficiencies found.
Standard Health Citation — quality of care: Routine/emergency Dental Services In SNFs deficiencies cited.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment deficiencies noted.
Life Safety Code Citation — NFPA requirements: Alcohol Based Hand Rub Dispenser deficiencies found.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Power Cords And Extensions deficiencies cited.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Testing And Maintenance deficiencies noted.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System deficiencies found.
Life Safety Code Citation — NFPA requirements: Exit Signage deficiencies cited.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance deficiencies noted.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure deficiencies found.
Life Safety Code Citation — NFPA requirements: Portable Space Heaters deficiencies cited.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficiencies noted.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrier deficiencies found.
Life Safety Code Citation — NFPA requirements: Vertical Openings - Enclosure deficiencies cited.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices deficiencies noted.
Standard Health Citation — quality of care: Investigate/prevent/correct Alleged Violation deficiencies found.
Standard Health Citation — quality of care: Smoking Policies deficiencies cited.
Standard Health Citation — quality of care: Treatment/services Mental/psychosocial Concerns deficiencies noted.
Report Facts
Inspections on page: 4
Total violations/deficiencies cited: 54
Inspections with violations: 3
Inspections without violations: 1
Plan of correction counts: Not stated
Total fines: 30000
Number of enforcement actions: 3
Total complaints: 83
On-site inspections from complaints: 12
Citations issued from complaints: 14
Inspection Report — Aug 29, 2025
Annual Inspection CMS
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.
Citations (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 — Nov 17, 2023
Annual Inspection CMS
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.
Citations (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 — Aug 9, 2021
Abbreviated Survey CMS
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.
Citations (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. |
Viewing
Loading inspection reports...
