Betsy Ross Rehabilitation Center, Inc

In the surveyor’s words

From the most serious findings on record at Betsy Ross Rehabilitation Center, Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 21, 2021

  Based on record review and interview during the abbreviated survey (NY 563) conducted on [DATE], the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 6 (Resident #1) residents reviewed. Specifically, Resident #1 had a history of shoveling food in their mouth, taking other residents' food, pocketing food, and was on a mechanical soft diet. The facility failed to include in the resident's care plan the speech-language pathologist's (SLP) recommendations for one bite then one sip of food at a time with close supervision when eating. The facility failed to ensure the resident's meal ticket was specific for the ordered mechanical soft diet and did not document the consistency of each food to be provided to the resident. […]

• Actual harm, isolatedF689Feb 29, 2024

  Based on observation, record review, and interview during the abbreviated survey (NY00321876), the facility did not provide an environment free of hazards or adequate supervision to prevent accidents for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 sustained a burn to their right foot when unit helper #1 transported them in their wheelchair with a carafe of hot coffee resting between their feet. Additionally, after the resident sustained the burn, licensed practical nurse #2 applied toothpaste to the burn without a physician's order. This resulted in actual harm of a second-degree burn (partial thickness skin damage with blistering) to Resident #1 that was not Immediate Jeopardy. […]

• No harm, potential for more than minimal, patternF584Dec 1, 2023

  Based on observation, record review, and interview during the recertification survey conducted November 27, 2023, to December 1, 2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 2 resident Wings (Wings 1 and 2) reviewed. Specifically, hot water temperatures were measured above 120 degrees Fahrenheit in resident rooms on Wings 1 and 2; and multiple ceiling tiles and a wall with water damage were left uncorrected on Wings 1 and 2. Findings include: The facility policy Water Temperature Testing was requested on November 30, 2023. The policy provided was signed by the Administrator as reviewed on November 30, 2023. The date of the previous review was unknown. […]

• No harm, potential for more than minimal, patternF812Dec 1, 2023

  Based on observation, record review, and interview during the recertification survey conducted November 27, 2023, through December 1, 2023, the facility did not store, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, potentially hazardous foods were not cooled properly; there were unclean kitchen surfaces; and the dishwasher temperatures were not within acceptable range. Findings include: The facility policy Nutrient Retention of Foods dated June 2019, documented the facility will endeavor to prepare and serve food in such a manner as to conserve the nutritive value of foods. Food to be prepared and refrigerated before service will be chilled to storage temperature in 2 hours or less. […]

• No harm, potential for more than minimal, patternF689Oct 8, 2021

  Based on observation, record review and interview during the recertification survey and abbreviated surveys (NY 050, NY 363 and NY 990) conducted 10/5/21-10/8/21, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (Residents #37 and #219) reviewed. Specifically, - Resident #37 eloped and following the incident, the resident was moved to a secured unit. When the resident was moved off of the secured unit, a plan was not developed and implemented to ensure increased supervision was provided. - Resident #219 was a supervised smoker who sustained a burn when adequate supervision was not provided during smoking. […]