Beacon Harbor Healthcare and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Beacon Harbor Healthcare and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 22, 2024

  Based on observations, record reviews and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #139) resident of three residents reviewed for assisted transfer. The facility failed to ensure on 02/01/2024 PT K used the Hoyer lift ( mechanical/patient lift designed to assist caregivers move patients from one place to another) correctly, attach the Hoyer lift sling pad and condcuted with assistance of a second person as care planned, when he transferred Resident #139 from his wheelchair to the bed. […]

• Immediate jeopardy, isolatedF689Jun 30, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents received adequate monitoring and supervision to prevent elopement for 1 of 1 (Resident #133) reviewed for accidents hazards/supervision. The facility failed to implement interventions to prevent elopement and failed to adequately supervise Resident #133 to prevent him from leaving the facility on 06/05/2023 without staff knowledge. Resident #133 was located 0.4 miles away from the facility. This failure could place residents requiring supervision at risk for serious injury and death. In Immediate Jeopardy (IJ) was identified to have existed from 06/05/2023 to 06/05/2023. […]

• Actual harm, isolatedF684Sep 20, 2023

  Based on interview and record the facility failed to ensure, based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents choices for 1 of 5 residents (Resident #7) reviewed for quality of care. The facility failed to ensure Resident #7 was accurately assessed, monitored, and treated for a change of condition when the resident was found to be in pain on 09/10/23 at approximately 10:30 PM. Resident #7 was not immediately sent to the hospital for emergency medical care. She was sent to the hospital on 09/11/23 after therapy staff notified the nurse of a leg deformity. […]

• No harm, potential for more than minimal, widespreadF812Nov 20, 2025

  Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for food safety.1. The facility failed to correctly discard food by the use by date for 1 storage bag of cheese.2. The facility failed to discard a dented can of soup.3. The facility failed to use or discard a tray with four containers of sliced/chopped vegetables by the discard dateThese failures could place residents at risk for food-borne illness and cross contamination.Findings included:Observation of the kitchen on 09/23/2025 at 9:40 a.m., revealed in the walk in refrigerator a storage bag containing sliced cheese was observed with a use by date of 09/21/2025. […]

• No harm, potential for more than minimal, patternF800Mar 24, 2026

  Based on observation, interview, and record review, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for three (Resident #1, #2, and #3) of ten residents reviewed for food preferences. The facility failed to provide hot palatable oatmeal at the breakfast meal for Residents #1, # 2, 3, and #4. This deficient practice could put residents at risk of weight loss, an increase of feelings of self-worth, and a decreased quality of life. Findings included: Record Review of Resident #1's quarterly MDS assessment, dated 03/10/2026, revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. […]