Beacon Brook Center for Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Beacon Brook Center for Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 2, 2024

  Based on review of the clinical record, review of facility documentation, and staff interviews for 1 of 1 sampled resident (Resident #101) reviewed for non-compliance with smoking, the facility failed to provide adequate supervision and failed to implement interventions to prevent an accident hazard after repeated incidents of noncompliance related to smoking. These failures resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #101 was admitted to the facility on [DATE]. The resident's diagnoses included cellulitis of abdominal wall, alcohol abuse and nicotine dependence. Resident #101 had a conservator of both estate and person. […]

• Actual harm, isolatedF686May 2, 2024

  Based on observation, review of the clinical record reviews, facility policy, and interviews for 2 of 4 residents (Resident # 418) reviewed for pressure ulcers, the facility failed to perform wound care as prescribed by the physician to prevent further skin breakdown and for (Resident # 90), the facility failed to ensure weekly skin audits were completed in accordance with the facility policy. The findings included: 1. Resident #418 was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, traumatic spinal cord dysfunction, and paraplegia (paralysis of the legs and lower body). The care plan dated 6/20/22 for at risk for further skin breakdown. […]

• Actual harm, isolatedF689Jun 22, 2022

  Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident # 1) reviewed for abuse, the facility failed to ensure adequate supervision was in place to prevent (sexual) abuse. The findings include: Resident # 1 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], intracranial injury with loss of consciousness unspecified duration, dementia with behavioral disturbance and Alzheimer's disease. […]

• No harm, potential for more than minimal, patternF578Jan 5, 2026

  Based on review of the clinical record, facility policy and interviews for 1 of 24 sampled residents (Resident #41) reviewed for advanced directives, the facility failed to ensure advanced directives were consistent throughout the clinical record. The findings include:Resident #41's was admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis (a rare muscle injury where your muscles break down), epilepsy (seizure disorder) and major depressive disorder. A facility Advanced Directive Consent/Acknowledgement and Release Form signed by Resident #41 and LPN #9 on [DATE] identified Resident #41 did not want Cardiopulmonary Resuscitation (CPR), Artificial Respiration and Artificial Nutrition administered. […]

• No harm, potential for more than minimal, patternF804Jan 5, 2026

  Based on observation, resident/staff interviews, and facility policy, the facility failed to ensure that food items were maintained at a palatable and appetizing temperature at time of serving. The findings include: Food Committee Meeting Minutes from 1/13/25, 2/24/25, 4/21/25, 5/19/25, 6/16/25, and 7/23/25 identified resident complaints of cold food.On 1/2/25 at 12:20 PM a test/temperature tray was conducted with the Director of Dietary and the following was identified:At 12:26 PM the test tray was prepared and plated in the kitchen located on the basement floor. The test meal was plated on a heated dish, placed in a plastic base, covered with a plastic dome, and put onto a meal tray. The meal tray was then placed in a closed meal delivery truck with other resident trays. […]