Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beecher Manor Nrsg & Rehab Ctr during CMS and state inspections, most recent first.
A Maintenance Assistant kissed a resident who had schizophrenia, legal blindness, and other psychiatric diagnoses, despite knowing the relationship was inappropriate because he was an employee and she was a resident. A CNA saw them kissing in the resident’s room, and the employee admitted the contact occurred. Staff later described the resident as tearful and withdrawn, and the SSD noted the care plan had not been updated to reflect the sexual abuse concerns.
A resident meal service issue involved late tray delivery and food served at temperatures that were not palatable. Residents were observed waiting for lunch while trays arrived in multiple carts, one resident did not receive lunch until after being moved to the shower room, and another resident waited at the nurse’s station before getting a tray. The Dietary Manager found the meal items were too cool, staff reported meals were often served late and cold, and a cart lacked an insulated base because the facility had run out of them.
Restorative Nursing Services Not Consistently Provided: Residents with ROM, mobility, walking, transfer, and bed mobility programs reported not receiving the ordered restorative care, and surveyors observed some residents sitting near the nurse’s station without restorative engagement. Staff said restorative aides were often pulled to cover CNA shifts and focused first on residents due for MDS review, with restorative tasks done only if time allowed. Facility schedules showed multiple days when restorative staff were reassigned or not scheduled, and documentation contained gaps and entries showing sessions completed despite reports that the care had not occurred.
Resident privacy was not maintained when an outside man was brought into a resident's room while she was using a bedside commode. The resident, who was cognitively intact and needed assistance with toileting and transfers, said the man did not knock or introduce himself and stayed in the room despite her asking to come back later. The RN said she escorted the man to the room and left him there, and the Administrator confirmed the resident's privacy was not maintained.
A resident with malnutrition, dysphagia, dementia, and other serious conditions was ordered a pureed diet with honey-thick liquids and 1:1 feeding assistance, but staff documented the resident as a partial self-feed and did not address a rapid weight loss from 121 to 108 pounds. The resident was not followed by the RD after the loss was identified, the NP visit did not address it, and the DON said she was unaware of the weight loss and no new dietary orders were placed. The family member reported staff were not feeding the resident and that the food provided was not enough.
A resident with multiple comorbidities, impaired coordination, and difficulty walking, care-planned as high risk for falls and requiring partial to moderate assistance with transfers, was transferred from bed to wheelchair by a CNA without use of a gait belt or the resident’s walker, contrary to the resident’s care card and facility policies. During this unsafe transfer, the resident’s feet slipped and the resident fell to the floor, sustaining bruising to the face and flank, a skin tear to the elbow and forearm, redness to the knee and ankle, and significant pain. An RN, PTA, restorative nurse, administrator, and DON all confirmed that the resident was supposed to be a one-person assist with a gait belt and walker, and facility guidelines specified gait belt use and individualized fall-risk interventions to prevent such incidents.
Surveyors found that two residents with dementia, histories of repeated falls, and other significant conditions such as Parkinson’s disease, fractures, and bone disorders were not provided with ordered low-bed fall precautions. Both residents had a leaf symbol posted by their room names indicating fall risk, and care documentation specified use of a low bed, yet each was repeatedly observed in bed with the bed raised about two feet from the floor rather than in the lowest position. A CNA reported being unaware of specific fall precautions for one resident, while the ADON/RN stated that when low-bed precautions are in place, beds should be lowered as close to the floor as possible when residents are in bed.
A resident with Parkinson's disease, a fractured femur, and a history of repeated falls was being assisted by a CNA who, despite observing heavy jerking movements and recognizing the need for a second staff member, attempted to position the resident on the side of the bed alone. The CNA did not request help from her available partner, and the resident subsequently fell, sustaining a scalp laceration that required staples. Facility policy and staff interviews confirmed that two staff were required for such transfers, and this protocol was not followed.
Two residents with dementia and cognitive impairment were involved in a physical altercation, resulting in one resident sustaining abrasions and scratches to the face and neck. The aggressive resident had exhibited prior exit-seeking and aggressive behaviors, including an attempt to choke an LPN, but remained in the facility after being started on new medications. The altercation was not directly witnessed by staff, and both residents were assessed and separated following the incident.
The facility failed to maintain kitchen hygiene and food safety, affecting 112 residents. Observations included sticky floors, improperly labeled and stored food items, inadequate sanitization levels, and inconsistent monitoring of food temperatures. The Dietary Consultant was seen without proper facial hair covering, and water was dripping from the ceiling, causing a wet kitchen floor. These issues indicate non-compliance with the facility's policies on sanitization, food storage, and personnel health.
The facility failed to provide adequate hygiene care for several residents, including a cognitively impaired resident with saturated incontinence briefs and reddened skin, a resident left in a wet undergarment for hours, a female resident with unwanted facial hair, and a resident with long, curled fingernails. These deficiencies highlight a lack of adherence to care policies and timely interventions.
The facility failed to implement proper fall precautions for four residents at risk for falls. A resident was found with her bed in a high position, contrary to her care plan. Another resident had a floor mat only on one side of the bed, despite needing mats on both sides. Two other residents were similarly observed with inadequate mat placement, despite their care plans indicating the need for mats on both sides due to their fall risk and medical conditions. The DON confirmed the expectation for high fall risk residents to have beds in low positions with mats on both sides.
The facility failed to follow Enhanced Barrier Precautions (EBP) and hand hygiene protocols, as staff did not wear gowns during care for residents with catheters and wounds, and did not perform proper hand hygiene after handling potentially contaminated equipment. Additionally, improper perineal care was observed, with a CNA using the same cloth multiple times, risking cross-contamination.
A facility failed to provide a portable oxygen tank holder for a resident requiring continuous oxygen, leading to the resident experiencing shortness of breath while using the bathroom without oxygen. The resident, with chronic respiratory conditions, could not bring her oxygen due to her bariatric wheelchair's size. The LPN and DON acknowledged the oversight, noting the facility had portable holders but did not use them, despite the resident's need.
The facility failed to maintain consistent advance directives for two residents, leading to discrepancies between electronic health records and the Advance Directive book. For one resident, the electronic record showed a Full Code Status while the book had a DNR form, and for another, the electronic record had a DNR form while the book showed a Full Code form. The DON acknowledged the need for consistency to ensure correct life-sustaining measures are provided.
A resident with moderate cognitive impairment was improperly restrained in bed using interconnected bolsters and side rails without a physician's order or care plan. The facility's policy requires physician review before restraint use, which was not followed.
A facility failed to provide a resident or their representative with written notice of the bed hold policy before the resident was transferred to the hospital. The resident was sent to the hospital due to labored breathing, low oxygen saturation, low blood pressure, and a high heart rate. The DON confirmed the lack of documentation and stated that staff are expected to provide the bed hold policy during hospital transfers.
A resident with mild cognitive impairment did not receive wound care as per the physician's order. The wound care nurse failed to apply Hydrofera Blue to the resident's right hip wound, citing a discussion about changing the dressing. However, the wound care physician clarified that the updated order was for Calcium Alginate with form dressing, which was not reflected in the system, leading to the deficiency.
The facility failed to provide adequate restorative care services for two residents, leading to deficiencies in their care. One resident did not receive consistent passive range of motion exercises or wrist splint application as per their care plan. Another resident reported not receiving the expected active range of motion exercises and assistance with bed mobility, which was confirmed by facility documentation. Staff prioritized residents with upcoming MDS assessments, resulting in inadequate restorative care for others.
The facility failed to label, date, and discard old food and beverages in two residents' personal refrigerators. One resident had old ice cream sandwiches, and another had cups with unknown liquids, both unlabeled and undated. The facility's policy requires labeling and discarding perishable items after three days. Both residents had multiple diagnoses, with one being cognitively intact and the other severely impaired.
The facility failed to maintain a pest-free environment, with house flies and gnats observed in resident rooms and common areas. A resident with moderate cognitive impairment reported flies in her room and on her person. The Assistant Director of Nursing acknowledged the issue, and the Maintenance Director stated that the facility is treated by a pest control company twice a month. The facility's pest control policy outlines measures to prevent and eradicate pests.
A resident with morbid obesity and hemiplegia suffered a femur and nasal fracture after a siderail broke during bed mobility assistance. The resident required two staff for assistance, but only one was present, contrary to the care plan. The incident highlighted a communication failure regarding the resident's care needs.
Staff Member Kissing Resident
Penalty
Summary
The facility failed to ensure a resident was free from exploitation and sexual abuse by a Maintenance Assistant. The resident had diagnoses including schizophrenia, legal blindness, heart failure, cognitive communication deficit, psychotic disorder with hallucinations, and major depressive disorder, and was taking a daily antipsychotic medication. Her care plan identified her as at risk for abuse due to schizophrenia, and her MDS documented intact cognition. The facility’s abuse policy defined abuse to include sexual assault and mental anguish, and defined exploitation as taking advantage of a resident for personal gain through manipulation. A CNA reported seeing the Maintenance Assistant and the resident kissing behind the resident’s door while delivering breakfast. The CNA stated the resident’s hands were on the employee’s neck and shoulders, and the employee appeared startled when he saw her. The Maintenance Assistant later stated the resident would wait for him in the hallway, would come close to his face because she was blind, and would tell him she loved him and wanted him to take her out of the facility. He admitted he knew kissing the resident was wrong because he was an employee and she was a resident, and he described kissing her in her room with his hands on her waist when the CNA walked in. Multiple staff members described the incident as sexual abuse, and the Administrator stated that a staff member kissing a resident is sexual abuse. The Maintenance Director reviewed camera footage showing the employee and resident together in the hallway and then in the resident’s room before the CNA entered. After the incident, staff observed the resident crying, listening to love songs, staying in her room, and telling staff she was not okay and that she and the employee were in love. The Social Service Director stated the resident declined to discuss what happened and that the care plan had not been updated to include the sexual abuse concerns.
Late Meal Delivery and Cold Food
Penalty
Summary
Food and drink were not provided in a timely manner to ensure palatability for 3 of 3 residents reviewed for dietary services, including R4, R5, and R7. On 07/09/26, residents were observed waiting in the main dining room for lunch while trays were still being delivered to the nursing station and then to the unit in multiple carts. R4 had not received her lunch tray by 12:15 PM and stated meals had been served about an hour late for the last month, with food that was always cold and never warm. R4 also stated there had been times when breakfast was served at 11:00 AM, lunch at 2:00 PM, and dinner at 7:30 PM. R5 was still waiting at the nurse’s station at 1:20 PM and did not receive a tray until 1:23 PM. R4’s tray was delivered late to her room, and she was then taken to the shower room before eating. When she returned at 2:02 PM, she stated she did not want the lunch because it was cold and said she would eat a sandwich she already had. The meal served to R4 was chicken pot pie with gravy, peas, a brownie, and cranberry juice. The Dietary Manager tested the food temperature at 2:10 PM and found the chicken pot pie was 100 F and the peas were 90 F, stating the food should be hotter for the meal to be palatable. The Dietary Manager also stated residents’ lunch trays should not be served to their rooms at 1:23 PM, and that R4’s hallway trays were last to be delivered. R7 stated the last food cart did not have the insulated base because the facility had run out of the bases. Staff and the Administrator stated meals were often served late, residents complained about cold food, and lunch trays should not be delivered after 1:00 PM or dinner after 7:00 PM. Grievances and Resident Council minutes also documented repeated concerns about late breakfasts, lunches, and dinners over the prior three months.
Restorative Nursing Services Not Consistently Provided
Penalty
Summary
The facility failed to ensure restorative nursing services were consistently provided in accordance with therapy recommendations and resident needs, and instead prioritized residents approaching MDS assessment review periods. The report states that restorative aides were reassigned to work on the floor and perform CNA/patient care duties, which resulted in restorative programming not being completed for residents on restorative plans. Surveyors observed residents sitting near the nurse’s station without engagement from staff for restorative programming or exercise on multiple occasions, and staff interviews confirmed that restorative tasks were often completed only after the MDS review list was addressed, if time allowed. Several residents with restorative plans and significant mobility limitations reported not receiving the ordered services. One resident with hemiplegia, hemiparesis, abnormal gait, and reduced mobility had a restorative plan for eating assistance, bed mobility, and PROM to the right hand and joints, yet was observed without restorative engagement and the record showed inconsistent implementation. Another resident with severe cognitive impairment and dependence for ADLs had a plan for AROM to both upper extremities, but was observed sitting near the nurse’s station without restorative activity. Additional residents with diagnoses including spinal stenosis, osteoarthritis, fractures, Parkinson’s disease, muscle wasting, repeated falls, and reduced mobility reported that no one had assisted them with ROM, walking, transfers, or bed mobility exercises, and several stated they had not seen restorative aides for weeks or months. Staff interviews corroborated the inconsistent delivery of restorative care. A restorative aide stated that residents due for MDS review were the priority and that other restorative programming was done only if time allowed; the aide also said restorative programming did not get done when reassigned to CNA duties. Other staff gave conflicting statements about whether CNAs were responsible for restorative care, while the restorative nursing director and DON acknowledged that restorative aides were frequently pulled to cover open shifts and that restorative care did not get done when this occurred. The facility’s schedules showed restorative staff removed from restorative assignments on multiple dates to cover CNA positions, with some days having no one scheduled for restorative care at all. Review of restorative documentation showed gaps and inconsistent completion, and some restorative sessions were recorded as completed despite staff and residents reporting that the programming had not been done.
Resident privacy was not maintained during an unauthorized room visit
Penalty
Summary
The facility failed to ensure privacy for 1 of 4 residents reviewed for personal privacy. R2 was admitted with multiple diagnoses including radiculopathy, spinal stenosis, difficulty walking, lack of coordination, abnormal posture, reduced mobility, muscle wasting and atrophy, hyperlipidemia, depression, anxiety, hypertensive chronic kidney disease, atrial fibrillation, and low back pain. R2's MDS showed the resident was cognitively intact and required supervision or touching assistance for toileting and transfers. The care plan noted that R2 refused to use the restroom in the resident's room and instead used a bedside commode. R2 filed a grievance after reporting that a man entered the room while her pants were down and no one knew who he was. R2 later stated that an outside African American man was brought to her room by an RN while she was using the commode, did not knock or introduce himself, and remained in the room despite her asking him and the RN to come back later. R2 said she felt her privacy was violated because she was forced to answer questions while sitting on the commode. The RN stated that a gentleman asked to interview R2, that she walked him to the room, believed R2 was in a wheelchair, and left him alone with R2. The Administrator said she was aware of the incident, assumed it was maintenance, and confirmed that resident privacy should be respected and people should knock before entering rooms; she also confirmed that R2's privacy was not maintained.
Failure to Meet Nutritional Needs and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that one resident’s nutritional needs were met. The resident had multiple diagnoses including moderate protein calorie malnutrition, dysphagia, dementia, diabetes, hemiplegia, reduced mobility, and other significant medical conditions. The MDS showed severe cognitive impairment and the resident required maximal assistance with eating and oral hygiene. The care plan identified a potential nutritional problem and directed staff to monitor for signs of malnutrition, including significant weight loss, while the dietitian was to evaluate and make diet change recommendations as needed. Physician orders included a low concentrated sweets, pureed diet with honey thickened liquids and one-to-one feeding assistance, but a nursing progress note later documented the resident as a partial self-feed despite that order. The resident’s weight declined from 121 pounds to 108 pounds within about three weeks, and the resident was last seen by the dietitian before that weight loss was identified. The nurse practitioner visit did not address the weight loss, and there were no additional dietitian notes or new dietary orders after the loss was documented. The resident’s family member reported that staff were not feeding the resident, that the amount of food provided was not enough, and that the family member often had to perform most of the care because staff were not providing it. A nurse stated the family member was not compliant with the specialized diet and often brought in additional food, and the DON stated she was unaware of the weight loss and confirmed no additional orders had been placed to address it.
Failure to Use Gait Belt and Walker During Transfer Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer for a resident at high risk for falls, resulting in a fall with injury. The resident was an elderly female with asthma, rheumatoid arthritis, type 2 diabetes, lack of coordination, muscle wasting and atrophy, difficulty walking, and osteoarthritis. Her care card directed staff to use a walker for stand-pivot transfers, and her MDS indicated she required partial to moderate assistance with transfers. Her care plan identified her as high risk for falls, with interventions including anticipating and meeting her needs and following fall protocol. On the date of the incident, the resident was found on the floor on her right side holding her head, with bruising around the right eye, redness to the right knee and ankle, a skin tear to the right forearm, and reported pain of 7 out of 10. Hospital records documented facial contusion, arthralgia, and a skin tear. Staff interviews and facility policies confirmed that required safety measures were not followed during the transfer. The CNA who transferred the resident reported that she moved the resident from bed to wheelchair without using a gait belt or the resident’s walker, and the resident’s feet slipped, causing her to fall to the floor on her right side and sustain a cut to her right elbow. The RN assigned to the resident that day stated that the resident was a one-person assist for transfers and that staff were required to use a gait belt and the walker, but at the time of the fall the resident had no gait belt on and the walker was not near her. The PTA and restorative nurse both stated that the resident was to be transferred with a gait belt and walker, and the restorative nurse confirmed she had updated the care card before the fall to specify walker use for standing and pivoting. The administrator and DON acknowledged that the gait belt and walker should have been used. Facility policies on gait belt use and fall risk management described gait belts as safety devices to aid in transfers and ambulation and indicated that staff should implement resident-specific interventions to prevent falls.
Failure to Maintain Low-Bed Fall Precautions for High-Risk Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to follow fall-prevention interventions for residents assessed as high risk for falls. One male resident with dementia, Parkinson’s disease, muscle wasting and atrophy, lack of coordination, and a history of repeat falls had a leaf symbol posted by his name outside his room, and his care card in the room closet listed “low bed” as a fall precaution. On multiple observations on January 23 and January 24, this resident was found lying in bed with the bed raised approximately two feet from the floor and not in the lowest position. The resident reported having had a fall at the facility. A CNA who had been assigned to this resident the previous day stated she was not aware of any specific fall precautions for him, despite the documented intervention of a low bed. A second resident, a female with dementia, non-pathological and pathological fractures, disorders of bone density and structure, and repeated falls, also had a leaf symbol posted by her name outside her room. She was observed lying in bed sleeping with the bed raised approximately two feet from the floor and not in the lowest position, while she stated she was trying to get some rest. The Assistant DON/RN explained that fall risk assessments are completed on admission, quarterly, annually, as needed, and after new falls, and that the facility reviews all falls and prior interventions. She further stated that when fall precautions include a low bed, the bed should be in the lowest position when the resident is in bed, and that the beds can be lowered very close to the floor. Despite these stated practices and documented precautions, both high-risk residents were observed with beds not maintained in the low position as ordered.
Failure to Provide Required Supervision During Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to implement required safety measures to prevent a fall for a resident with a high risk for falls. The resident, who had diagnoses including a displaced fractured left femur, Parkinson's disease, and a history of repeated falls, was being assisted with personal hygiene and dressing by a Certified Nurse's Assistant (CNA) who had not previously cared for the resident and had not received a report from the off-going staff or nurse. During care, the resident's upper body was shaking and jerking heavily. Despite recognizing the need for a second staff member and a full body mechanical lift, the CNA proceeded to slide the resident to the side of the bed and placed her in a sitting position without assistance. While the CNA reached for a wipe, the resident jerked again and fell off the bed, resulting in a 3-centimeter laceration to the scalp that required staples for closure. Interviews with facility staff, including the LPN, DON, and the resident's primary care physician, confirmed that facility policy and standard practice required two staff members to be present when positioning a resident with such conditions on the side of the bed prior to transfer, especially when using a sit-to-stand mechanical lift. The CNA's partner was available but was not asked to assist. The resident's records indicated a high fall risk, and the facility's policy required staff to identify and implement interventions to minimize fall risks and complications. The failure to follow these protocols directly led to the resident's fall and injury.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between two residents, both of whom had diagnoses of dementia and compromised cognitive function. One resident, who had recently been admitted and assessed as having compromised mental status, exhibited exit-seeking and aggressive behaviors, including an incident where he attempted to choke a nurse. Despite these behaviors, the resident remained in the facility and was started on new medications following the initial aggression. The following day, the same resident became physically aggressive toward another resident, striking and scratching him in the face and neck area. The incident was not directly witnessed by staff, but was reported by the affected resident, who sustained abrasions and scratches. Both residents were separated after the incident, and assessments revealed injuries consistent with the reported altercation. The aggressive resident was unable to recall the event, and both residents had significant cognitive impairments that limited their ability to provide detailed accounts. Prior to the altercation, staff had observed the aggressive resident's exit-seeking and agitation, including a physical attack on a staff member. The facility's response to these behaviors included notifying the resident's power of attorney, consulting with a psychiatric nurse practitioner, and administering new medications. However, the resident remained in the facility and subsequently engaged in resident-to-resident physical abuse, resulting in injury.
Deficiencies in Kitchen Hygiene and Food Safety Practices
Penalty
Summary
The facility failed to maintain the kitchen in a manner that would prevent foodborne illness, affecting 112 residents who receive meals from dietary services. During a kitchen tour, it was observed that the dry storage floors were sticky, and several food items, including vanilla wafers and spaghetti, were opened without proper labeling of open or use-by dates. In the walk-in cooler, a bag of mixed vegetables and a five-gallon bucket of pickles were found without proper labeling, and jars of marinara sauce had broken seals. Additionally, deli sandwiches were kept beyond the recommended 48 to 72 hours, and there were no logs for sanitization buckets. The walk-in freezer contained non-food items, and the sanitization bucket in use measured below the required 200 ppm. The facility's documentation revealed inconsistent monitoring of chemical sanitization levels and food temperatures. The Dietary Consultant, V25, was observed in the kitchen without proper facial hair covering, and water was dripping from the ceiling, causing the kitchen floor to be wet. The facility's policies on sanitization, food storage, and personnel health were not adhered to, as evidenced by the lack of proper labeling, inadequate sanitization levels, and improper storage of food items. These deficiencies indicate a failure to follow professional standards for food safety and hygiene, potentially leading to foodborne illness among residents.
Deficiencies in Hygiene and ADL Care
Penalty
Summary
The facility failed to provide adequate hygiene care and maintenance for several residents, leading to deficiencies in their care. Resident R65, who is cognitively impaired and dependent on staff for all care needs, was found with an overly saturated incontinence brief and reddened coccyx and perineum. Despite being assessed as high risk for skin breakdown, there was no order for zinc cream until after the issue was observed by staff. This indicates a lack of timely intervention to prevent skin irritation and potential breakdown. Resident R106, who is cognitively intact but dependent on staff for care, reported not receiving incontinence care since early morning, despite staff being aware of her needs. Her incontinence brief was found saturated with urine, and she expressed distress over being left in a wet undergarment. The facility's policy requires incontinence care every two hours, which was not adhered to, resulting in discomfort and potential risk for skin issues. Additional deficiencies were noted with residents R4 and R90. R4, who has moderate cognitive impairment, was observed with long chin hairs, which she expressed a desire to have removed. Staff acknowledged that facial hair on female residents is a dignity issue, yet it was not addressed. R90, with severe cognitive impairment, had long, curled fingernails despite being dependent on staff for personal hygiene. The facility's guidelines require regular nail care to prevent injury, which was not provided, posing a risk of self-injury and infection.
Failure to Implement Fall Precautions for At-Risk Residents
Penalty
Summary
The facility failed to implement proper fall precaution measures for four residents identified as being at risk for falls. Resident R33 was observed with her bed in a high position, contrary to her care plan which required the bed to be in the lowest position with brakes locked. This was noted by the Assistant Director of Nursing. Resident R14 was found with a floor mat only on the left side of her bed, despite her care plan indicating the need for mats on both sides due to her risk factors including a history of cerebral vascular accident and decreased mobility. Similarly, Resident R52 was observed with only one mat on the right side of his bed, while his care plan required mats on both sides due to his history of falls and conditions such as Parkinson's disease and dementia. Resident R69 was also observed with only one mat on the left side of his bed on two separate occasions, despite his care plan indicating the need for mats on both sides due to his history of falls and multiple medical conditions. The Director of Nursing confirmed that the expectation for high fall risk residents is to have beds in low positions with mats on both sides, which was not adhered to in these cases.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) Guidelines, as observed in the care of four residents. Staff did not wear gowns during incontinent care for residents with wounds, catheters, and other conditions requiring EBP. For instance, a Licensed Practical Nurse (LPN) and Certified Nursing Assistants (CNAs) provided care to a resident with a suprapubic catheter and nephrostomy tube without wearing gowns, despite the facility's guidelines requiring such precautions. Additionally, the facility did not provide trash cans inside resident rooms and near exits for proper disposal of personal protective equipment (PPE), further compromising infection control measures. In another instance, a CNA moved a Foley catheter bag with ungloved hands and then proceeded to handle a resident's meal tray without performing hand hygiene. This action was contrary to the facility's hand hygiene policy, which mandates hand cleaning after contact with potentially contaminated equipment and before handling food. The resident involved had a history of urinary tract infections, highlighting the importance of strict adherence to infection control practices. Furthermore, during perineal care for a resident, a CNA used the same cloth towel multiple times without folding or changing it, which could lead to cross-contamination. The CNA admitted to rushing the procedure, which compromised the quality of care. The facility's perineal care policy requires using a clean cloth for each wipe to prevent infections and skin irritations. These deficiencies indicate a lack of compliance with established infection prevention protocols, potentially affecting resident safety and care quality.
Failure to Provide Portable Oxygen Tank Holder for Resident
Penalty
Summary
The facility failed to provide a portable oxygen tank holder for an ambulatory resident who requires continuous oxygen. The resident, who has chronic obstructive pulmonary disease, morbid obesity, and chronic respiratory failure, was observed lying in bed with 4 liters of oxygen per nasal cannula. The resident reported that she could walk to the bathroom independently but did not have a way to bring her oxygen with her due to her bariatric wheelchair being too wide to fit into the bathroom. As a result, she experienced shortness of breath while using the bathroom without her oxygen. The Licensed Practical Nurse (LPN) acknowledged that the facility had portable oxygen tank holders but did not use them because residents had oxygen tank holders on their wheelchairs. The LPN was aware of the resident's situation and that she went to the bathroom without her oxygen. The Director of Nursing (DON) confirmed that an ambulatory resident with a continuous oxygen order should be able to go to the bathroom with their oxygen on and that the resident should have been provided with a portable oxygen tank holder. The facility's policy on oxygen administration requires reviewing the resident's care plan for special needs and assembling necessary equipment, including a portable oxygen cylinder.
Inconsistent Advance Directives for Two Residents
Penalty
Summary
The facility failed to maintain current and accurate advance directives for two residents, R69 and R115, as identified during a record review conducted by a state surveyor and the Director of Nursing (DON). For R69, there was a discrepancy between the electronic health record, which showed a Full Code Status POLST Declaration form dated 6/21/24, and the Advance Directive book at the nurses' station, which contained a DNR form dated 2/23/21. Similarly, for R115, the electronic health record indicated a DNR form dated 5/11/24, while the Advance Directive book showed a Full Code form dated 2/16/24. The DON acknowledged that both the Advance Directive book and the electronic health record should be consistent to ensure the facility provides the correct life-sustaining measures as per the resident's wishes. The facility's Advance Directive policy, dated November 2016, mandates that copies of written advance directives be uploaded into the residents' clinical records. Additionally, for staff without access rights to these records, the residents' advance directives should be maintained on the nursing unit and be available for staff reference when rendering care and services. The inconsistency between the records and the Advance Directive book could lead to the facility not administering the appropriate life-sustaining measures desired by the residents.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility was found to have improperly used physical restraints on a resident, identified as R81, who is a [AGE] year-old female with moderate cognitive impairment. During an observation on 8/29/24, R81 was seen with a wedge to her right upper body, both upper side rails up, and two bolsters interconnected with a strap at the bottom of the bed, effectively confining her to the bed. The Assistant Director of Nursing acknowledged that these bolsters, without a physician's order, could be considered a restraint. The resident's care plan did not include the use of bed bolsters, and there was no physician order for their use in the physician order sheet for August 2024. The Director of Nursing confirmed that a physician order and care plan should have been in place for the use of bolsters. The facility's physical restraint policy, dated February 2014, states that restraints should not be used for punishment or staff convenience and requires physician review before ordering or reordering restraint use.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to a resident or their representative before the resident was transferred to the hospital. The deficiency was identified during a review of the resident's electronic health record, which showed that the resident was sent to the hospital due to labored breathing, low oxygen saturation, low blood pressure, and a high heart rate. There was no documentation indicating that the resident or their representative received a copy of the facility's bed hold policy. The Director of Nursing confirmed the absence of such documentation and stated that it is expected for the facility staff to provide the bed hold policy when a resident is transferred to the hospital.
Failure to Follow Updated Wound Care Orders
Penalty
Summary
The facility failed to follow the physician's order for wound care for a resident with mild cognitive impairment. During an observation, it was noted that the wound care nurse did not apply Hydrofera Blue to the resident's right hip wound as per the physician's order. The wound care nurse admitted to changing the dressing the previous day but could not explain why Hydrofera Blue was not used. The physician's order sheet specified cleansing the wound with saline, applying Hydrofera Blue, and covering it with a dry dressing. Further investigation revealed a communication breakdown regarding the wound care orders. The wound care nurse stated that there was a discussion about changing the dressing from Hydrofera Blue to Santyl, which led to the omission. However, the wound care physician clarified that the most updated order was for Calcium Alginate with form dressing, and the staff should have updated the system to reflect this new order. This miscommunication resulted in the failure to provide the correct wound care as per the physician's updated instructions.
Failure to Provide Adequate Restorative Care Services
Penalty
Summary
The facility failed to provide adequate restorative care services for two residents, leading to deficiencies in their care. One resident, who is cognitively impaired and dependent on staff for all care needs, was supposed to receive passive range of motion (PROM) exercises and have a wrist splint applied regularly. However, documentation showed inconsistencies in the provision of these services, with the resident not having the splint on during observations and receiving PROM less frequently than planned. The resident's care plan was not followed as intended, indicating a lapse in the facility's restorative care services. Another resident, who is cognitively intact but dependent on staff for hygiene, dressing, and repositioning, was supposed to receive active range of motion (AROM) exercises and assistance with bed mobility. The resident reported not receiving the expected restorative visits and exercises as frequently as outlined in their care plan. The facility's documentation confirmed the resident's claims, showing a significant gap between the planned and actual delivery of restorative services. Staff interviews revealed that residents with upcoming MDS assessments were prioritized, leading to other residents, like this one, not receiving the necessary restorative care.
Failure to Label and Discard Old Food in Residents' Refrigerators
Penalty
Summary
The facility failed to properly label, date, and discard old food and beverages from residents' personal refrigerators, as observed in the cases of two residents. One resident had nine soft, old ice cream sandwiches in her personal refrigerator's freezer, which were not labeled or dated. Despite the resident stating that staff assists her with cleaning the refrigerator, the ice cream sandwiches remained in the freezer over multiple days. The housekeeper was unaware of the old ice cream sandwiches, and the Director of Nursing acknowledged that all residents' food should be labeled and dated to prevent potential illness. This resident had multiple diagnoses, including heart failure and dementia, but was cognitively intact according to her MDS. Another resident's personal refrigerator contained three cups with an unknown liquid, which were also not labeled or dated. The resident confirmed she consumes the drinks, and the cups remained in the refrigerator over several days. The housekeeper and Director of Nursing both stated that all liquids should be labeled and dated to avoid potential illness. The facility's policy requires that any food or beverage must be dated and labeled, and perishable items not consumed after three days should be discarded. This resident had severe cognitive impairment and multiple diagnoses, including chronic kidney disease and dementia.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain a pest-free environment for its 117 residents, as evidenced by the presence of house flies and gnats in resident rooms and common areas. A specific incident involved a female resident with moderate cognitive impairment who reported flies in her room and on her person. Observations by the surveyor confirmed the presence of house flies in the resident's room and around the food cart in front of the kitchen hallway. Additionally, flies and gnats were observed around the North and South Nurse's stations. The Assistant Director of Nursing acknowledged the widespread presence of flies. The Maintenance Director stated that the facility is treated by a pest control company twice a month, with the last treatment occurring on 8/16/24, and acknowledged the need for a pest-free environment for residents. The facility's pest control policy, dated 11/1/23, outlines ongoing measures to prevent and eradicate common household pests, including flies.
Failure to Provide Adequate Bed Mobility Assistance Results in Resident Injury
Penalty
Summary
The facility failed to provide safe bed mobility assistance for a resident, resulting in significant injuries. The resident, who had diagnoses including morbid obesity, hemiplegia, and contractures, required the assistance of two staff members for bed mobility. However, during an incident, a nursing assistant provided care alone, contrary to the resident's care plan. While the resident was being turned onto her side, she used the siderail for support, which broke, causing her to fall to the floor. This fall resulted in a right femur fracture, a nasal fracture, and a laceration requiring sutures. The incident was further compounded by a lack of awareness among staff regarding the resident's care needs. The Director of Nurses discovered that the care card used by staff incorrectly indicated that the resident required only one person for assistance, despite assessments and the care plan specifying a two-person assist. Interviews with other nursing assistants confirmed that the resident was known to require two staff members for safe bed mobility due to her size and limited mobility. The facility's failure to ensure accurate communication of the resident's care needs and to provide adequate supervision during care led to the accident. The siderail, although rated for high weight capacity, broke under the force exerted during the incident. The resident's cognitive status was intact, and she was dependent on staff for mobility, highlighting the importance of following the care plan to prevent such accidents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 831 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beecher
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St James Wellness Rehab Villas | 7.3 mi | ★★★★★ | 1 | 0 |
| Bria Of Chicago Heights | 9.5 mi | ★★★★★ | 2 | 0 |
| Landmark Of Richton Park Rehab & Nsg Ctr | 10 mi | ★★★★★ | 23 | 0 |
| Aperion Care Chicago Heights | 10.3 mi | ★★★★★ | 16 | 0 |
| Great Lakes Healthcare Center | 11.2 mi | ★★★★★ | 38 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.