Inspection Reports for Beacon Harbor Healthcare and Rehabilitation

The complaint investigation found the facility failed to notify Resident #1's responsible party when the resident's midline IV was removed on 12/03/2025, despite the resident having a significant change in condition. Interviews with staff and the responsible party confirmed the failure to notify, which is against facility policy.

The facility failed to notify Resident #1's responsible party when the resident's midline IV was found removed from his arm, resulting in potential risk due to lack of timely communication about the resident's change in condition. Interviews and record reviews confirmed the failure to notify the responsible party despite policy requirements.

The facility was found deficient in maintaining a safe, clean, and homelike environment as evidenced by stained bed sheets for Resident #1, failure to review and revise the comprehensive care plan quarterly for Resident #1, and inaccurate nursing documentation regarding new bruises for Resident #2. These deficiencies posed minimal harm or potential for actual harm to a few residents.

The complaint investigation substantiated that the facility failed to maintain resident privacy during personal care for four residents due to broken blinds and inadequate window coverings. It also substantiated a serious incident where a resident fell from a Hoyer lift due to improper transfer technique by a physical therapist, resulting in multiple fractures and brain hemorrhage. The physical therapist was terminated and the facility implemented staff training and competency checks. Additionally, food safety violations were identified related to improper labeling, storage, and sanitation in the kitchen.

The facility failed to ensure privacy for residents during personal care due to broken blinds and inadequate window coverings, placing residents at risk of embarrassment and loss of dignity. Additionally, the facility failed to follow safe transfer protocols resulting in a resident falling from a Hoyer lift and sustaining serious injuries. The facility also failed to maintain proper food labeling, storage, and sanitation in the kitchen, risking foodborne illness.

The facility failed to ensure resident privacy during incontinent care due to broken or missing window blinds, failed to maintain a safe and homelike environment including clean vents, intact baseboards, and safe handrails, failed to properly label and store food items in the kitchen, and failed to ensure staff performed hand hygiene during meal service, placing residents at risk for privacy violations, unsafe environment, foodborne illness, and infection transmission.

The complaint was substantiated. Resident #1's family reported that on 06/02/24, Resident #1 was given another resident's medications and not his insulin. The facility confirmed the error and took corrective actions including staff re-training.

The facility failed to provide pharmaceutical services to meet the needs of Resident #1 by giving him the medications of Resident #2 during therapeutic leave, placing residents at risk of harm. The error was identified and reported promptly, and staff involved were re-trained on medication administration and leave of absence medication procedures.

The complaint investigation found that the facility did not notify the hospice agency immediately of Resident #1's falls and change in condition on 02/22/24 and 02/25/24. The hospice supervising nurse confirmed not being informed by the facility. The Director of Nursing stated hospice was verbally notified on 02/26/24 but not documented. The complaint was substantiated with minimal harm.

The facility failed to notify the hospice agency immediately about Resident #1's falls and change in condition, which could place residents at risk of health decline. Interviews and record reviews confirmed the lack of timely notification and documentation despite notification of the physician and family. Facility policies on significant change in condition and end-of-life care were reviewed.

The complaint investigation found that Resident #1's appointments were not scheduled and the facility assigned a physician not familiar with her care needs. The resident's responsible party (RP) expressed concerns about lack of continuity of care and transportation. The facility staff acknowledged the issues and noted that a grievance should have been filed but was not initiated.

The facility failed to honor Resident #1's right to choose her primary care physician as her attending physician upon readmission, resulting in concerns about continuity of care and appointment scheduling. Interviews and record reviews confirmed that Resident #1 was assigned a facility physician instead of her chosen PCP, and follow-up appointments were not scheduled as per hospital discharge instructions.

The complaint investigation was triggered by multiple resident and family member reports of inadequate housekeeping, delayed or missed incontinent care, failure to administer prescribed pain medication, and failure to properly assess and treat a resident's pain and injury.

The facility failed to maintain a sanitary environment in resident rooms, ensure timely incontinent care for residents, accurately assess and treat a resident's change in condition resulting in fractures, and administer prescribed medications as ordered. Documentation and communication deficiencies were also noted.

The complaint investigation revealed multiple issues including environmental sanitation failures affecting Resident #82, an elopement incident involving Resident #133 due to inadequate supervision and elopement prevention, medication storage security lapses, food safety violations, infection control breaches, and pest control deficiencies.

The facility failed to maintain a safe and sanitary environment for Resident #82, including pest control and housekeeping deficiencies. Resident #133 eloped from the facility due to inadequate supervision and lack of effective elopement prevention measures. Medication carts were left unlocked, risking unauthorized access. Food service staff failed to follow sanitation protocols. Infection control practices were not followed, including failure to sanitize equipment between residents. Pest control was inadequate, allowing spider infestation in a resident's room.

The complaint investigation was substantiated based on observations, interviews, and record reviews showing failures in resident dignity, incontinence care, and food service temperature.

The facility failed to treat Resident #2 with dignity during incontinence care, leaving the resident uncovered. Resident #1 did not receive timely incontinence care, resulting in poor hygiene and skin issues. Additionally, food served to Residents #1 and #3 was not at an appetizing temperature, posing risks to nutritional status.

The facility failed to ensure proper pharmaceutical services, including failure to report a damaged blister pack of medication and the presence of expired blood glucose control solutions on a nurse's medication cart. These issues posed risks of medication errors, drug diversion, and inaccurate blood sugar readings.