Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Betsy Ross Rehabilitation Center, Inc during CMS and state inspections, most recent first.
A resident with respiratory failure, hypoxia, wheezing, and confirmed COVID-19 was placed on contact/droplet transmission-based precautions with orders for isolation and in-room services, but staff repeatedly failed to follow the facility’s COVID-19 policy and posted enhanced contact-droplet signage. Multiple staff, including therapy personnel, CNAs, a floor technician, an outside vendor, and a social work director, entered and exited the resident’s room without required PPE such as N95 respirators, gowns, gloves, and eye protection, and often did not perform hand hygiene despite the resident actively coughing. The PPE bin outside the room was incompletely stocked, lacking N95s, eye protection, and hand sanitizer at times, and staff reported having to search other bins or ask where to obtain missing items, even though they acknowledged that the signage required full PPE and that it should be available in the bin.
The facility failed to provide timely access to medical records to a resident's legal representative after the resident, who had severe cognitive impairment and multiple behavioral and fall-related diagnoses, had been discharged home on hospice and subsequently died. The family submitted a completed authorization form and death certificate, but the Director of Medical Records did not forward the request to the third-party compliance vendor until more than two working days later, due in part to multiple competing duties and a misunderstanding of the required timeframe. As a result, the legal representative did not receive access to the requested records within the required two working days of the written request.
Failure to Follow COVID-19 Transmission-Based Precautions and Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program and follow transmission-based precautions for a resident with confirmed COVID-19. The resident had diagnoses including respiratory failure with hypoxia, wheezing, and COVID-19, was cognitively intact, and dependent on staff for transfers. The resident’s care plan and physician orders documented that the resident was COVID-19 positive and required contact/droplet transmission-based precautions, isolation in a private room, and that all activities, including therapy, dining, and activities, be brought to the room. Facility policy and the enhanced contact-droplet precaution signage required staff to perform hand hygiene when entering and leaving the room, wear an N95 respirator, gown, gloves, and eye protection, keep the door closed when safe, and use disposable or dedicated equipment. Surveyors observed multiple instances where staff and an outside vendor entered and exited the COVID-19 positive resident’s room without appropriate PPE and without performing hand hygiene. On several occasions, therapy staff, a floor technician, an unidentified outside vendor, CNAs, and the Director of Social Work entered the room without gowns, gloves, N95 respirators, or eye protection, despite enhanced contact-droplet precaution signage posted on the door. Some staff wore only an N95 or only a surgical mask, and others wore no PPE at all. Staff frequently failed to perform hand hygiene upon entering or exiting the room, even after touching the inside of the resident’s door or handling items such as meal trays and a rolling walker. The resident was observed coughing during some of these encounters. The PPE bin outside the resident’s room was found to be incompletely stocked, containing only vinyl gloves, procedure masks, and isolation gowns, with no N95 respirators, eye protection, or hand sanitizer at one point. Staff interviews revealed that they understood the signage indicated the need for a gown, gloves, N95 mask, and eye protection for COVID-19 precautions, and that these items should be in the PPE bin, but they reported that N95 masks and eye protection were missing and that they sometimes took N95s from other bins or would have to ask where to get more eye protection. The Infection Preventionist/Staff Development Nurse stated they were responsible for signage and PPE bins, that the signage was intended to match the resident’s condition, and that staff were expected to follow the signage and perform hand hygiene after exiting the room. The administrator and medical director both stated that the purpose of the signage was to prevent the spread of infection and that precautions should be followed. The resident reported that staff did not always wear gowns, hardly wore gloves, and were never seen with face shields or goggles, and that therapy staff had provided care without gowns, gloves, masks, or face shields. Overall, the observations, record review, and interviews showed that the facility did not ensure that staff consistently adhered to its COVID-19 policy, the posted enhanced contact-droplet precautions, and basic hand hygiene practices when caring for a resident with confirmed COVID-19. The failure included incomplete stocking of required PPE in the bin outside the resident’s room, staff entering and exiting the room without required PPE, and repeated failures to perform hand hygiene, despite clear signage and staff acknowledgment of the required precautions.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records to a resident's legal representative as required by regulation and facility policy. The facility's policy dated 12/02/2025 stated that residents could request access to their medical information orally or in writing, and that such requests would be submitted in a timely manner to the corporate compliance vendor for approval and tracking. Resident #3, who had diagnoses including anxiety, bipolar disorder, repeated falls, and severe cognitive impairment per a 06/05/2023 MDS, was discharged home on hospice on 07/27/2023. After the resident's death, the family requested medical records. On 03/25/2025, the Director of Medical Records sent the family an authorization form, and on 04/07/2025 the family returned the completed authorization form and death certificate. Despite receipt of the completed request on 04/07/2025, the Director of Medical Records did not submit the request and supporting documents to the third-party corporate compliance company until 04/24/2025. The Director of Medical Records acknowledged that the request may have been missed or not handled timely due to competing responsibilities, which included scheduling appointments, referrals, transportation, managing provider dictations, scanning and uploading external records, and other medical records duties. The Director also believed records requests needed to be completed within 30 days, rather than the regulatory requirement of two working days for access. The Administrator stated that the Director of Medical Records was responsible for medical records requests and that staff would forward any such requests to that individual. The delay from 04/07/2025 to 04/24/2025 in submitting the request to the third-party company resulted in the resident's legal representative not receiving access to the medical records within two working days of the written request, in violation of 10 NYCRR 415.3(c)(1)(iv).
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Gardens Skilled Living Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Rome Memorial Hospital, Inc - R H C F | 1.1 mi | ★★★★★ | 0 | 0 |
| The Grand Rehabilitation And Nursing At Rome | 1.1 mi | ★★★★★ | 29 | 1 |
| Colonial Park Rehabilitation And Nursing Center | 2 mi | ★★★★★ | 25 | 0 |
| Trustees Of Eastern Star Hall & Home Of The N Y S | 8.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.