Beechwood Home for Incurables

In the surveyor’s words

From the most serious findings on record at Beechwood Home for Incurables, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF803Apr 28, 2022

  Based on observations, review of a therapeutic spreadsheet, record review, review of the facility's policy, and staff interviews, the facility failed to serve the correct portion sizes for a pureed diet. This affected eight residents (#13, #19, #31, #40, #48, #52, #53, and #57) residing in the facility whom receive puree diets. The facility census was 71. Findings include: Review of the facility's therapeutic spreadsheet revealed the pureed diet consisted of pork loin three ounce measuring scoop, grilled buttered asparagus four ounce measuring scoop, roasted sweet potatoes four ounce measuring scoop, and hot spiced apples four ounce measuring cup. Observation on 04/27/22 at 11:58 A.M. […]

• No harm, potential for more than minimal, isolatedF919Jan 22, 2026

  Based on observations, policy review, staff interviews, and record review, the facility failed to ensure call lights were withing reach of the residents. This affected two (Resident #362 and #543) of the 70 residents who are able to utilize the call light system. The facility census was 73.Findings include:1. Medical record review for Resident #362 revealed an admission date of 09/15/06. Diagnoses included multiple sclerosis (MS), lack of coordination and epilepsy. Care plan intervention revealed Resident #362 was able to use call light system when placed in right hand. Velcro strap needs to be attached to call light is wrapped around right hand and resident brings call light up to his chin to activate.Observation and interview on 01/22/26 at 11:00 A.M. […]

• No harm, potential for more than minimal, isolatedF609May 22, 2025

  Based on staff interview, record review, review of the facilities Self-Reported Incident (SRI) and investigation, and policy review, the facility failed to report to law enforcement an allegation of staff-to-resident physical abuse. This affected one (Resident #70) of one resident reviewed for abuse. The facility census was 73. Findings include: Review of Resident #70's medical record revealed Resident #70 admitted to the facility on [DATE]. Resident #70 had a medical history which included pseudobulbar effect and post-traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. […]

• No harm, potential for more than minimal, isolatedF645May 22, 2025

  Based on staff interview and record review, the facility failed to ensure the level one Preadmission Screening and Resident Review (PASARR) accurately reflected a resident's existing mental illness at the time of admission. This affected one (Resident #69) of two residents reviewed for PASARR . Findings include: Review of Resident #69's medical record revealed Resident #69 admitted to the facility on [DATE]. Diagnoses included dementia, post-traumatic stress disorder (PTSD), and epilepsy. Review of the PASARR Identification Screen dated 02/09/23 revealed Resident #69 did not have any of the diagnoses or disorders listed on the form. […]

• No harm, potential for more than minimal, isolatedF760May 22, 2025

  Based on staff interview, record review, and facility policy review, the facility failed to ensure a resident was free from significant medication errors, when the facility failed to follow a physician's order to hold a blood pressure medication when the systolic blood pressure (SBP), the top number in a blood pressure (BP)) reading was above 120. This affected one (Resident #7) of six residents reviewed for unnecessary medications. The facility census was 73. Findings include: Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral palsy, hyperlipidemia, and acute kidney failure. […]