Beacon Hill

In the surveyor’s words

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

• Immediate jeopardy, patternF757Jul 14, 2022

  Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs and without adequate monitoring for one of six residents (Resident #239) reviewed for unnecessary medications. The facility failed to conduct adequate therapeutic drug monitoring of Resident #239's lab levels, for 2 out of 3 opportunities, while receiving [MEDICATION(S)] which resulted in Resident #239 being sent to the hospital on 03/12/22 and diagnosed with acute kidney failure. A past Immediate Jeopardy (IJ) situation was identified on 07/13/22. The IJ occurred from 03/01/22 (Resident #239's first missed opportunity for therapeutic drug monitoring) to 03/12/22 (date of discharge). On 03/12/22 the IJ was lowered to actual harm. […]

• No harm, potential for more than minimal, patternF577Dec 18, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF585Dec 18, 2025

  Based 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.Findings included: In a confidential group interview on 12/17/25 at 11:00 AM with 6 residents revealed all residents did not know how to file a grievance and were unaware of who to discuss their individual grievances with. […]

• No harm, potential for more than minimal, patternF755Dec 18, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF677Sep 26, 2024

  34918 Based 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. […]