Beacon Hill

In the surveyor’s words

From the most serious findings on record at Beacon Hill, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 2, 2025

  Based on observation, interview and record review, the facility failed to safely transfer a resident (R1) who required maximum assistance. The facility also failed to assess, identify, and provide specific and consistent interventions to ensure safety during a transfer. This failure resulted in R1 sustaining a left leg laceration requiring 29 staples at the hospital. This applies to 1 of 3 residents (R1) reviewed for safe transfer and accidents. The findings include: The EMR (Electronic Medical Record) shows that R1, an [AGE] year-old with diagnoses that includes encephalopathy, muscle weakness, congestive heart failure, morbid obesity, atherosclerosis heart disease, coronary artery disease and Crohn's disease. R1 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF686Jun 12, 2024

  Based on observation, interview, and record review the facility failed to identify a pressure injury before becoming a deep tissue injury and failed to ensure pressure reducing interventions were in place for 2 of 3 residents (R34, R12) reviewed for pressure injuries in the sample of 14. These failures contributed to R34 developing a deep tissue injury and the worsening of R12's deep tissue injury. The findings include: 1. On 06/10/24 at 12:56 PM, R34 was sitting up in his wheelchair at the bedside with the over bed tray table in front of him eating lunch. R34's left heel was resting directly on the floor. R34 stated I have a sore on my bottom due to radiation and one on my heel that developed here from my heel being on the bed too much. […]

• Actual harm, isolatedF689Dec 28, 2023

  Based on interview and record review the facility failed to follow the resident's care plan to provide the assistance of 2 staff during resident transfer. This failure resulted in a resident experiencing a fracture of the left lower leg (oblique fracture of proximal tibia and fibula of the left leg). This applies to 1 of 3 residents (R1) reviewed for transfers requiring assistance of 2 staff in the sample of 3. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], and discharged on [DATE]. […]

• No harm, potential for more than minimal, widespreadF803Jul 3, 2025

  Based on interview and record review, the facility failed to provide six servings of Grains/Breads daily on the facility menu. This applies to all 40 residents residing in the facility. The findings include: Facility Long Term Care Facility Application for Medicare and Medicaid, dated June 30, 2025, shows the facility census was 40 residents. Facility Diet Type Report, printed July 1, 2025, shows 39 residents receiving oral diets at the facility were receiving either General, Pureed, Mechanical Soft, Consistent Carbohydrate or Heart Healthy Diets. […]

• No harm, potential for more than minimal, widespreadF880Jul 3, 2025

  Based on interview and record review, the facility failed to have a complete water management plan for Legionella. The facility also failed to ensure the existing water management plan for Legionella was followed. This applies to all 40 residents residing in the facility. The findings include: The facility's Long-term Care Application for Medicare and Medicaid dated June 30, 2025, showed the facility census was 40 residents. On July 2, 2025, at 12:13 PM, V9 (Director of Plant Operations) said the only monitoring conducted in the facility's water management plan for Legionella is testing the water for Legionella. V9 said the last time the facility tested for Legionella was June 24, 2024. V9 said the facility does not have a complete water management plan for Legionella. […]