Beechwood Health Care Center, Inc.

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (#NY00383549) the facility did not ensure that residents are free of significant medication errors for one (1) (Resident #1) of three (3) residents reviewed. Specifically, on 06/11/2025 Licensed Practical Nurse #1 erroneously administered Resident #2's morning medications to Resident #1 which resulted in a significant medication error. The finding is:The policy and procedure titled Medication Administration effective 05/11/2023 documented medications shall be administered in accordance with established procedures including right resident, right medication, right dose, right time, right route, right reason, and right documentation. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 11/8/23, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for two (Resident #6 and #66) of seven residents reviewed for quality of care related to accidents and positioning. Specifically, there was lack of assessments and monitoring for Resident #6 after they spilled coffee on themselves, and Resident #66 was not provided with leg rests while they were in their wheelchair. Additionally, while sitting in their wheelchair, Resident #66's feet were hanging down and were approximately six inches from touching the floor for extended periods of time.

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey completed on 1/14/2022, the facility did not ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin are reported to the administrator as required for one (Resident #74) of one resident reviewed. Specifically, staff did not report facial bruising to their supervisor, Director of Nursing or the Administrator. The finding is: The facility policy and procedure (P&P) titled, Abuse, Neglect, Mistreatment, Misappropriation of Property or Exploitation: Care - Resident Rights dated 11/1/2016 documented; if a staff member has a concern regarding a resident's care, they will notify their immediate supervisor, the Director of Nursing or the Administrator. All accidents/ incidents involving residents will be assessed by the RN (registered nurse); [...]

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 1/14/22, the facility did not store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for two of two medication storage cabinets ([NAME] and [NAME] Units) observed for safe medication storage. Specifically, two medication cabinets located in common areas were observed unlocked with over-the-counter medication bottles ([NAME] and [NAME] Units) and one medication cabinet contained 21 prescription blister packs and two prescription nebulizer (inhaled) medications ([NAME] Unit). The finding is: 1. Review of the facility policy titled Medications Administering-Equipment & Supplies effective 1/8/09 revealed the facility maintains equipment and supplies necessary for the preparation and administration of medications to residents. [...]

Inspectors wroteBased on observation and interview during the Standard survey completed on 1/14/22, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Specifically, shower plumbing devices and hoses did not have vacuum breakers installed to prevent backflow in eight ([NAME]/Pines House tub/shower room, Wells/[NAME] tub/shower room, Harmony House tub/shower room, [NAME] House tub/shower room, [NAME] House tub/shower room, [NAME] House tub/shower room, Horizons House low side tub/shower room, Horizons House high side tub/shower room) of eleven tub/shower rooms located in two (East Village Building and [NAME] Village Building) of two resident use buildings.

Inspectors wroteBased on observation, interviews, and record review conducted during the Standard survey, completed on 5/9/19, the facility did not ensure that a resident who is fed by enteral means (method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements) receives the appropriate treatment and services to prevent possible complications for one (Resident #218) of two residents reviewed for feeding tubes. Specifically, the facility did not provide tube feed formula as ordered by the physician. In addition, the nursing staff documented the formula was administered as ordered. The finding is: 1. Resident #218 was admitted [DATE] and has diagnoses that included a gastrostomy tube (GT, tube feed), throat cancer, protein calorie malnutrition, and borderline gluten intolerance (wheat allergy). [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 5/9/19, it was determined that the facility did not maintain all mechanical, electrical and patient care equipment in safe operating condition. Specifically, ten (Arms, [NAME], [NAME], Eschelman, Harmony, [NAME], Horizon, Hospice, [NAME], [NAME]) of 15 resident household washing machines reviewed for safe operating condition had black debris on the rubber door gaskets and stale mildew odors in the washers.

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 5/9/19, the facility did not ensure that a written summary of the baseline care plan, that included initial goals, a list of current medications, dietary instructions, and services/treatments to be administered by facility and personnel acting on the behalf of the facility, was provided to the resident or the resident's representative. Specifically, 17 (Residents #16, 21, 44, 58, 99, 118, 127, 158, 162, 180, 184, 218, 219, 233, 282, 431, 481) of 17 admitted residents reviewed for Baseline Care Plans had no documented evidence that Baseline Care Plans were completed or that a written summary of the baseline care plan was provided to the resident and/or the resident's representative by completion of the comprehensive care plan.