Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beechwood Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, and wandering behavior entered another resident’s room and became agitated when staff tried to redirect him/her. An RN responded with a stern, loud, escalating voice and was heard yelling that the resident could not hurt the other resident, while other staff reported the reaction increased the resident’s agitation. The DON stated that stern and screaming at a resident was disrespectful and inconsistent with the facility’s Residents’ Rights policy requiring kindness, respect, and dignity.
Failure to Suspend Alleged Staff Member During Abuse Investigation: A resident with mild neurocognitive disorder and anxiety alleged that an LPN was rough during BP taking, ignored the resident, and gave meds late. The facility’s investigation later found the allegation unsubstantiated, but the LPN still worked on the unit while the investigation was pending, despite policy requiring suspension of the alleged staff member.
A resident with CHF, neurocognitive disorder, anxiety, and other chronic conditions did not receive multiple physician-ordered medications at the scheduled time. An agency LPN fell behind on the morning med pass, and the resident's daily medications were not given until about 4 hours late. The RN was notified the LPN was far behind, but could not explain what support was provided, and the DON stated meds should be given within 1 hour of the scheduled time.
Interest earned on personal funds held in interest-bearing accounts was not credited to the accounts of multiple residents due to a manual process and lack of staff training. The facility's policy also did not address the requirement to apply interest to resident accounts.
The facility did not obtain or maintain signed advance directive forms for two residents and failed to transcribe a signed advance directive into the electronic medical record for another. In each case, required documentation was missing or incomplete, despite facility policy mandating timely completion and inclusion in the medical record. Staff interviews confirmed lapses in following procedures for advance directive documentation.
Two residents experienced failures in timely reporting of abuse and neglect allegations. One resident, with cognitive and physical impairments, reported inappropriate and belittling comments from a nurse aide, including remarks about weight, which were not promptly reported to the State Agency. Another resident, with severe cognitive impairment and incontinence, was found in a soiled brief by their responsible party, but the grievance was not investigated or reported as required. Facility policies for immediate reporting and investigation were not followed in either case.
The facility did not properly investigate or document allegations of abuse and neglect involving two residents—one who reported belittling and inappropriate comments from a nurse aide, and another who was found in a soiled brief by a responsible party. In both cases, required investigations and follow-up actions were not completed according to facility policy.
A resident with severe cognitive impairment and multiple care needs did not have their care plan reviewed and revised quarterly by an interdisciplinary team, as required. Documentation showed that care plan meetings were either not held or lacked participation from key departments, and the resident's representative was not consistently involved.
A resident dependent on staff for personal hygiene, with multiple serious health conditions, was repeatedly observed with lengthy and soiled fingernails despite documentation of completed bed baths. Staff interviews confirmed that nail care should be included during ADL assistance, but the resident did not receive this care as required by facility policy.
Surveyors found that several residents had medications, including prescription and over-the-counter drugs, left unsecured at their bedside without physician orders or self-administration evaluations. Additionally, alcoholic beverages were stored in a medication refrigerator with resident medications, contrary to facility policy. Staff interviews confirmed these practices were not in line with established procedures for medication security and storage.
Surveyors found a black substance inside the kitchen ice machine during a walkthrough with the DD. The DD indicated that cleaning was the responsibility of the Maintenance Director, but the facility lacked a full-time Maintenance Director and the DD had not checked the machine for cleanliness. Documentation showed the monthly maintenance checklist for the ice machine was not completed for one month, contrary to facility policy requiring regular cleaning and sanitization.
Staff Used Stern, Loud Redirection With Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure staff treated a resident with dignity and respect when the resident did not respond to redirection. Resident #1 had diagnoses including dementia, restlessness and agitation, generalized muscle weakness, frequent falls, and anxiety. The resident’s MDS showed a BIMS score of 0, wandering behavior in the prior seven days, and a need for assistance with personal hygiene. The care plan identified impaired cognition and wandering behaviors, with interventions to face the resident when speaking and to reapproach later and redirect as needed when restless or agitated. The event involved Resident #1 entering another resident’s room and lying on that resident’s bed while the roommate was present. Staff observed Resident #1 saying the other resident was his/her baby, trying to get up to go to the other resident, and tapping the other resident on the head. RN #1 stood between the residents and attempted to redirect Resident #1, who became agitated. The facility reportable event and staff interviews described RN #1 using a stern, loud, and escalating voice, including statements such as changing tactics to be stern and yelling that Resident #1 could not hurt the other resident. RN #2 and nursing assistants reported that RN #1 appeared frustrated and that her reaction increased the resident’s agitation. Interviews with staff and the DON confirmed that RN #1 escalated her tone while trying to redirect the resident. RN #2 stated she told RN #1 not to react that way because it would make the resident more agitated, and then RN #2 was able to calm the resident by speaking gently and holding the resident’s hand. The DON stated that stern and screaming at a resident was disrespectful and that she would have expected RN #1 to ask for help and disengage when unable to redirect the resident. The facility Residents’ Rights policy required employees to treat all residents with kindness, respect, and dignity.
Failure to Suspend Alleged Staff Member During Abuse Investigation
Penalty
Summary
The facility failed to prevent further potential abuse while an investigation was in progress and failed to suspend the alleged staff member in accordance with facility policy. Resident #2 had diagnoses including mild neurocognitive disorder with behavioral disturbance and anxiety disorder, and a quarterly MDS assessment showed a BIMS score of 15, indicating the resident was alert and oriented and required staff assistance for personal care. The resident care plan identified impaired coping and pain and directed staff to evaluate the cause of anxiety or fear, provide care in a calm and reassuring manner, and provide medications as ordered. A reportable event documented an allegation of staff-to-resident abuse without injury after Resident #2 reported that an LPN did not provide medications timely, was ignoring the resident, and was rough when taking blood pressure. The facility’s summary stated the LPN was behind with medication pass, the resident refused the LPN’s offer to go to the room, the LPN obtained the blood pressure, and the supervisor administered the medications. The investigation later found abuse was not substantiated, but facility documentation and interview with the DON showed the LPN worked on the unit after the allegation was made and before the investigation was completed, despite the facility policy directing that the alleged staff member be suspended pending the outcome of the investigation.
Late Administration of Ordered Medications
Penalty
Summary
The facility failed to provide physician-ordered medications to Resident #2 in a timely manner. Resident #2 was admitted with diagnoses including congestive heart failure, mild neurocognitive disorder with behavioral disturbance, and anxiety disorder. A quarterly MDS assessment dated 6/12/2025 showed a BIMS score of 15, indicating the resident was alert and oriented, and the care plan identified impaired coping and pain. Physician orders dated 8/12/2025 directed multiple daily medications, including Bumetanide, Celexa, Oxybutynin ER, eye drops and gel for Sjogren syndrome, iron, Omeprazole ER, Tylenol, Cevimeline, B-complex, Calcitonin, Vitamin D3, Cranberry tablets, Vitamin B12, and multivitamins, with these medications scheduled for administration at 9 AM on 8/31/2025. Facility documentation and interviews showed the medications were not administered until 1 PM, approximately 4 hours after the scheduled time. A facility reportable event form documented that the LPN did not provide the medications timely, and the facility report summary identified the medications were administered late. The LPN stated she was an agency nurse unfamiliar with the unit and had fallen behind on the morning medication pass; she knew by 1 PM that Resident #2's medications had not yet been given and had notified the supervisor that she was behind. The RN stated she was told the LPN was very far behind in the medication pass, but could not explain what support or interventions were provided to ensure timely administration. The DON stated the medications were to be administered within one hour before or after the scheduled time and that the LPN should have notified the supervisor earlier so help could be provided.
Failure to Credit Interest to Resident Personal Funds Accounts
Penalty
Summary
The facility failed to credit interest earned to the personal funds accounts of 30 residents, both current and discharged, whose funds were held in an interest-bearing account managed by the facility. Review of clinical records, facility documentation, and interviews revealed that from April 2024 to May 2025, no interest was applied to individual resident accounts, as required by federal regulation. The Director of Revenue identified that the process for applying interest was manual and attributed the failure to a lack of proper training for the Business Manager responsible for managing resident personal fund accounts. Additionally, the facility's Personal Needs Account Policy and Procedure did not include guidance on the application of interest to resident accounts.
Failure to Properly Document and Maintain Advance Directives
Penalty
Summary
The facility failed to ensure proper documentation and handling of advance directives for three residents. For one resident with multiple serious diagnoses, including palliative care and cancer, there was no signed copy of the advance directive in either the paper or electronic medical record, despite physician notes and care plans referencing DNR/DNI/DNH status. Staff interviews revealed that the signed form was missing, possibly due to chart thinning, and the nursing supervisor was responsible for ensuring its presence, but it could not be located. Another resident, admitted with multiple sclerosis and other conditions, had a signed advance directive form indicating DNR status, but the code status order was not transcribed into the electronic medical record. Both an LPN and an RN confirmed the absence of the code status order in the system, despite facility policy requiring entry within 24 hours of admission. The DON acknowledged that the missing order could have resulted in care inconsistent with the resident's wishes. A third resident with dementia and other conditions did not have a signed advance directive in the clinical record, and the care plan failed to include an advance directive plan of care. There were conflicting physician orders regarding code status, and staff interviews confirmed that the required documentation was not completed as per facility policy. The facility's policy mandates that advance directive information be prominently displayed in the medical record and that the RN supervisor ensures completion within 24 hours of admission, which was not followed in these cases.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the State Agency as required, involving two residents. In the first case, a resident with bipolar disorder, morbid obesity, and chronic congestive heart failure, who was moderately cognitively impaired and dependent on staff for mobility and care, reported that a nurse aide was often in a bad mood, made dismissive comments such as 'this is just a job,' and made remarks about the resident's weight. The grievance form documenting these concerns was not signed by staff, and the Director of Nursing Services (DNS) did not report the allegation to the State Agency at the time, believing the resident wished to remain anonymous. The DNS also did not fully investigate the weight-related comment and only reassigned the nurse aide from the resident's care. Interviews confirmed that the comments were inappropriate and that the situation had potential for verbal abuse, but the required reporting did not occur until much later, after surveyor inquiry. In the second case, a resident with severe cognitive impairment, muscle weakness, and incontinence was found by their responsible party to be in pajamas late in the morning with a very soiled and odorous pull-up. A grievance was filed by the responsible party, and the social worker noted that staff would be re-educated on toileting rounds. However, there was no documentation of an investigation or staff education, and the DNS was unaware of the grievance until the survey. The DNS confirmed that if she had been aware, she would have reported the allegation to the State Agency, but this did not occur until prompted by the surveyor. The staff involved in the original grievance were no longer employed at the facility, and no further information was available from them. Facility policies required immediate reporting and investigation of any potential allegations of abuse, neglect, or exploitation. Despite these policies, the facility did not follow the required protocols for reporting and investigating the allegations in both cases. The lack of timely reporting and incomplete documentation contributed to the deficiency identified by surveyors.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to properly investigate and respond to allegations of abuse and neglect for two residents, as required by its own policies. In the first case, a resident with bipolar disorder, morbid obesity, and chronic congestive heart failure, who was cognitively impaired and dependent on staff for care, reported that a nurse aide was frequently in a bad mood, made dismissive comments such as 'This is just a job,' and made remarks about the resident's weight. The grievance form documenting this complaint was not signed by the staff member who completed it, and the Director of Nursing Services (DNS) did not conduct a thorough investigation at the time, citing confusion over the resident's desire for anonymity and not interviewing all involved parties or addressing all aspects of the complaint, such as the weight-related comments. In the second case, a resident with dementia, muscle weakness, and incontinence was found by a responsible party to be in a very soiled and odorous brief late in the morning. The grievance form indicated that staff would be re-educated on toileting rounds, but there was no evidence of an investigation or staff education being conducted. The DNS was unaware of the grievance and could not locate any documentation of follow-up or investigation. The staff members involved in the original grievance process were no longer employed at the facility, and no further information was available in the resident's records regarding the incident. Both incidents demonstrate that the facility did not follow its own grievance and abuse prohibition policies, which require immediate reporting and thorough investigation of any potential abuse or neglect. The lack of proper documentation, failure to interview all relevant parties, and absence of timely investigations contributed to the deficiencies identified by surveyors.
Failure to Conduct Interdisciplinary Quarterly Care Plan Reviews
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised on a quarterly basis with participation from an interdisciplinary team and the resident's representative. The resident in question had diagnoses including dementia, anxiety, and dysphagia, and was identified as severely cognitively impaired, requiring significant assistance with daily activities. Documentation showed that care plan meetings were either not held as required or lacked participation from key interdisciplinary team members such as nursing, dietary, therapy, or recreation. In several instances, only social services and the MDS coordinator attended, and there was no evidence that the resident's representative was consistently invited or present. Further review of the clinical record revealed gaps in the scheduling and documentation of care plan meetings over multiple quarters. Interviews with facility staff confirmed that other departments were not made aware of or invited to the meetings, and the resident's representative reported not being invited or attending recent meetings. The facility's policy required interdisciplinary review and input for care plan development and updates, but this was not followed, resulting in the deficiency.
Failure to Provide Fingernail Care During ADL Assistance
Penalty
Summary
A deficiency was identified when a resident, admitted with diagnoses including palliative care, breast cancer, chronic systolic heart failure, and atrial flutter, was observed to have lengthy and soiled fingernails with brownish debris under the nails on multiple occasions. The resident was documented as being dependent on staff for personal hygiene and had an ADL self-care performance deficit, requiring extensive assistance with personal hygiene as per the care plan. Despite a physician order for weekly skin inspections and a care card directing regular bathing or bed baths, records indicated that a bed bath was signed off as completed, yet the resident's fingernails remained unclean and untrimmed. Staff interviews revealed that nail care, including cleaning and trimming, was expected to be performed during bed baths or as needed, regardless of scheduled bath days. Supplies for nail care were available, and facility policy required assistance with ADLs to maintain grooming and hygiene for residents unable to perform these tasks independently. However, the observed condition of the resident's fingernails indicated that this care was not provided as required.
Failure to Secure Medications and Improper Storage in Medication Refrigerator
Penalty
Summary
Surveyors identified that the facility failed to ensure medications and biologicals were properly labeled and securely stored, as required by professional standards. During initial resident screenings, multiple residents were found with medications at their bedside, including prescription and over-the-counter drugs, without physician orders or completed self-administration evaluations. For example, one resident with COPD and sleep apnea had both an inhaler and a topical cream left on the over-bed table, and another resident with severe cognitive impairment had opened bottles of joint support capsules, Gas-X, and Aspercream accessible on the bedside table. A third resident with dementia and visuospatial deficits was observed with a bottle of Tums at the bedside. In each case, the residents did not have orders to self-administer medications, nor had they been evaluated for their ability to do so, and the medications were not secured as per facility policy. Additionally, the facility failed to maintain proper storage of medications and biologicals in medication refrigerators. Surveyors observed that alcoholic beverages, specifically bottles of wine and beer, were stored in a medication refrigerator alongside resident medications. The facility's policy explicitly prohibits the storage of non-medication items, such as food or beverages, in medication refrigerators. Despite this, the alcoholic beverages remained in the refrigerator during subsequent observations. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the presence of medications at the bedside without proper authorization and the storage of non-medication items in medication refrigerators were not in accordance with facility policy. Staff acknowledged that it was their responsibility to ensure medications were secured and that only medications should be stored in designated medication refrigerators.
Ice Machine Not Maintained in Sanitary Condition
Penalty
Summary
Surveyors observed a black substance inside the kitchen ice machine during a walkthrough with the Director of Dietary (DD). The DD stated that cleaning the ice machine was the responsibility of the Maintenance Director, but the facility did not have a full-time Maintenance Director at the time. The DD also admitted to never having checked the inside of the machine for cleanliness. Review of facility documentation showed that the monthly preventive maintenance checklist for the ice machine was not completed for one month, specifically May 2025. The facility's sanitization policy requires that all equipment, including ice machines, be cleaned and sanitized according to manufacturer instructions and facility policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New London
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harbor Village North Health And Rehabilitation Cen | 0.7 mi | ★★★★★ | 22 | 0 |
| Fairview | 1.4 mi | ★★★★★ | 3 | 0 |
| New London Sub-acute And Nursing | 1.5 mi | ★★★★★ | 22 | 3 |
| Greentree Manor Nursing And Rehabilitation Center | 3.1 mi | ★★★★★ | 7 | 0 |
| Complete Care At Groton Regency | 3.4 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.