Beacon Hill

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #1) of 1 resident reviewed for dignity. The facility failed to promote Resident #1's dignity when CNA B and CNA C talked disrespectfully to Resident #1 when she requested assistance. This failure could place residents at risk for a decrease in self-esteem, quality of life and self-worth. Record review of Resident #1's MDS assessment dated [DATE] indicated an [AGE] year-old female with initial admission date of [DATE] to the facility. Her pertinent diagnoses included: shortness of breath, muscle weakness, and cognitive communication deficit. Her BIMS score was 14, which indicated Resident #1' cognition was intact. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #2) of 3 residents reviewed for ADLs. The facility failed to ensure Resident #2 had his fingernails trimmed and cleaned on 05/26/2026. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and skin breakdown, and a decreased quality of life. Record review of Resident #2's Quarterly MDS assessment dated [DATE] indicated an [AGE] year-old male with initial admission date of 07/28/2022 to the facility. His pertinent diagnoses included: dementia (a decline in cognitive abilities, severe enough to interfere with daily life), and need for assistance with personal care. [...]

Inspectors wroteBased on observation and interview, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility and failed to ensure residents were informed of how to access most recent survey results reviewed for resident rights. The facility failed to post, in a place readily accessible to residents, family members and legal representatives of residents, the results of the most recent survey of the facility. The facility failed to ensure residents were informed of the right to review the results of the recent survey results for the facility. These failures could affect residents not being informed of their rights and informed of recent survey results of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were informed on how to file a grievance or complaint available to the resident reviewed for resident rights. The facility failed to ensure residents were informed on how to file a grievance and the grievance policy. These failures could place residents at risk of resident rights' violations, a decline in quality of life, and delay in resolving grievances.

Inspectors wroteBased on observation, interview, and record review, the facility to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of two medication rooms (Medication Room for Hall 600-700-800) reviewed for pharmaceutical procedures. The facility failed to ensure a vial of TB PPD that was opened and dated [DATE] was discarded and not been used beyond the 30-day expiration time after the open date. This failure may result in residents receiving medications with diminished effectiveness.n observation and interview on [DATE] at 08:46 a.m. of the Medication Room (for Hall 600-700-800) refrigerator with LVN B revealed an open vial of Tuberculin Purified protein derivative dated [DATE]. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the resident and resident's representative(s) of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 7 residents (Resident #89) reviewed for discharge planning. The facility failed to notify Resident #89 and Resident #89's responsible party of Resident #89's discharge, reasons for the move, and right to appeal in writing, in a language and manner they understand, and at least 30 days before Resident #89 was discharged from the facility on 12/15/25 in a facility-initiated discharge to a memory care facility. The facility failed to send a copy of the notice to the facility's Ombudsman before Resident #89 was discharged from the facility on 12/15/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #51) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #51's fingernails were clean. This failure could place residents who were dependent on staff for ADL care at a loss of dignity and a decreased quality of life. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for two of four medication carts (Cart for Hall 600, and cart for Hall 100) reviewed for pharmacy services. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #46) reviewed for infection control. The facility failed to ensure CNA A changed gloves and performed hand hygiene while providing incontinent care to Resident #46. This failure could place residents at risk of infection and cross contamination. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 1 of 6 residents (Resident #20) reviewed for residents' call system. The facility failed to provide a working communication system that was easily at reach, that would allow Resident #20 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. Record review of Resident #20's quarterly MDS assessment dated [DATE] reflected Resident #20 was a [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #16, Resident #93, Resident #94, Resident #57) of 21 residents reviewed for ADLs. The facility failed to ensure: 1. Resident #16 had his nails cut and cleaned. 2. Resident #93 had his fingernails cleaned and trimmed. 3. Resident #94 had his fingernails cleaned and trimmed. 4. Resident #57 had her fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at a loss of dignity and a decreased quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen for 3 of 4 Dietary Staff (Dietary [NAME] T, Dietary [NAME] U and Dietary Assistant [NAME] V) reviewed for kitchen sanitation. 1. The facility failed to ensure graham cracker crumbs were sealed in dry storage. 2. The facility failed to ensure sugar and flour container lids in dry storage were free of stickiness and white particles on them. 3. Dietary [NAME] T, Dietary [NAME] U and Dietary Assistant [NAME] V failed to perform hand hygiene during lunch meal service on 09/25/24. 4. The facility failed to ensure gravy was temped prior to being served on 09/25/24. These failures could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 23 residents (Resident #257 and Resident #24) reviewed for infection control. 1. The facility failed to ensure LVN H sanitized a bottle of glucose level test strips when she carried the bottle into Resident #257's room and returned it to the medication cart without sanitizing it. 2. The facility failed to ensure LVN H failed to perform hand hygiene after removal of her gloves after completion of obtaining a fingerstick blood sugar test on Resident #257, after cleaning the glucometer, and after insulin administration to Resident #257. 3. [...]

Inspectors wroteBased on interview and record review, the facility to ensure that the residents had the right to and that the facility promoted and facilitated resident self-determination for 1 (Resident #23) of 7 resident who were reviewed for resident rights. The facility failed to ensure Resident #23's right to make choices about aspects of his life that were significant to the resident by not ensuring his right to schedule his own appointments and involve him in the rescheduling process. This failure could place residents with the ability to make choices at risk of having their rights violated, diminished quality of life and unmet needs.

Inspectors wroteBased on observations, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 24 (Resident #57) of 24 residents reviewed for comprehensive care plans. The facility failed to develop a care plan for Resident #57's bed bath preference and her preference to stay in bed. This failure could place residents at risk of not having their needs and preferences met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain good foot health for 1 (Resident #57) of 8 residents reviewed for quality of care. The facility failed to ensure Resident #57 received foot care and treatment for her dry, flaky skin on her feet. The facility failed to ensure Resident #57 was referred and seen by podiatrist for her long thick toenails. These failures placed all residents at risk for not receiving foot care which is consistent with professional standards of practice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of five residents (Resident # 47) reviewed for catheter and incontinence care. The facility failed to ensure Unit Manager A and CNA E maintained the foley catheter drainage bag below Resident #47's bladder during a mechanical lift transfer. This failure placed residents at risk for not receiving care appropriate to address their incontinence.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of one resident (Resident #84) reviewed for medication administration for enteral feeding tubes. The facility failed to ensure LVN C clamped the tubing before it drained completely between each medication administration for Resident #84. This failure could affect residents by placing them at risk of abdominal discomfort and aspiration.

Inspectors wroteBased on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of two medication rooms (Medication Room X) reviewed for storage. The facility failed to ensure a vial of TB PPD that was opened and used was dated in the medication room refrigerator and failed to have 4 tuberculin syringes filled with an unknown liquid dated and labeled. These failures could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications.

Inspectors wroteBased on observations, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for facility's only kitchen reviewed for physical environment. The facility failed to ensure kitchen was free of two faucet leaks for 3 compartment sink and garbage disposal sink faucet. The pipe under the 3-compartment sink was dripping in three different areas under the 3-compartment sink. The drain in the dish area of the kitchen was loose around the edges. These failures could place facility at risk for unsanitary and hazardous living conditions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for one (Resident #8) of three residents reviewed for respiratory care. The facility failed to ensure the supplemental O2 was provided at the physician ordered liter amount for Resident #8. This failure could place residents who received oxygen therapy at risk of receiving an incorrect amount of oxygen and the risk of oxygen toxicity. Findings Included: Record review of Resident #8's quarterly MDS assessment dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS of 6 which indicated she was severely cognitively impaired. [...]