Inspection Reports for
Beechwood Homes

2235 Millersport Highway, Getzville, NY, 14068

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Inspection Report — Nov 25, 2025

Certification
Citations: 23 Date: Nov 25, 2025

Visit Reason
State-compiled facility profile showing 9 inspections from 2022 to 2026 with citation and enforcement history.

Complaint Details
The state logged 20 complaints about this facility; 11 led to on-site inspections. One citation resulted from those complaints.
Findings
Across 9 inspections, 6 had no citations while 3 inspections resulted in 36 citations mostly related to Life Safety Code issues. The facility had 20 complaints with 11 on-site inspections and 2 enforcement actions totaling $8,000 in fines.

Citations (23)
Standard Health Citation — quality of care: Services Provided Meet Professional Standards were found deficient.
Life Safety Code Citation — NFPA requirements: Aisle, Corridor, Or Ramp Width did not meet requirements.
Life Safety Code Citation — NFPA requirements: Cooking Facilities were not compliant.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System had multiple deficiencies.
Life Safety Code Citation — NFPA requirements: Emergency Lighting was deficient.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance was deficient.
Life Safety Code Citation — NFPA requirements: HVAC system was deficient.
Life Safety Code Citation — NFPA requirements: Illumination Of Means Of Egress was deficient.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General was deficient.
Life Safety Code Citation — NFPA requirements: Smoke Detection was deficient.
Life Safety Code Citation — NFPA requirements: Soiled Linen And Trash Containers were deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing was deficient.
Life Safety Code Citation — NFPA requirements: Travel Distance To Exits was deficient.
Standard Health Citation — quality of care: Residents Are Free Of Significant Med Errors was deficient.
Standard Health Citation — quality of care: Quality Of Care was deficient.
Life Safety Code Citation — NFPA requirements: Corridor - Doors were deficient.
Life Safety Code Citation — NFPA requirements: Exit Signage was deficient.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Installation was deficient.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storage was deficient.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure was deficient.
Life Safety Code Citation — NFPA requirements: Maintenance, Inspection & Testing - Doors was deficient.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrier was deficient.
Report Facts
Inspections on page: 9 Total violations/deficiencies cited: 36 Inspections with violations: 3 Inspections without violations: 6 Total complaints: 20 On-site complaint inspections: 11 Citations from complaints: 1 Enforcement actions: 2 Total fines: 8000

Inspection Report — Jul 3, 2025

Complaint Investigation
Citations: 1 Date: Jul 3, 2025

Visit Reason
The inspection was conducted as a complaint investigation (#NY00383549) regarding a significant medication error involving residents at the facility.

Complaint Details
The complaint investigation (#NY00383549) substantiated a significant medication error involving two residents. The error was reported immediately, and corrective actions including monitoring and intravenous fluids were implemented. The Medical Director confirmed the error and its mild, short-term impact.
Findings
The facility failed to ensure residents were free from significant medication errors when a Licensed Practical Nurse administered Resident #2's medications to Resident #1, resulting in low blood pressure and lethargy for Resident #1. The Medical Director was notified and new orders were implemented to monitor and treat the resident.

Citations (1)
F 0760: Ensure that residents are free from significant medication errors. A Licensed Practical Nurse erroneously administered Resident #2's medications to Resident #1, causing adverse effects including low blood pressure and lethargy. The facility failed to follow medication administration policies.
Report Facts
Residents reviewed: 3 Medication error date: Jun 11, 2025 Medication monitoring frequency: 2 Intravenous fluid volume: 1000

Employees mentioned
NameTitleContext
Licensed Practical Nurse #1Named as the nurse who administered the wrong medications
Director of NursingProvided statements regarding the medication error and its significance
Medical DirectorNotified of the error, gave new orders, and commented on the impact of the medication error

Inspection Report — Nov 8, 2023

Routine
Citations: 1 Date: Nov 8, 2023

Visit Reason
The inspection was a standard survey conducted to evaluate the facility's compliance with care standards, focusing on quality of care related to accidents and positioning for selected residents.

Findings
The facility failed to ensure residents received treatment and care according to professional standards and their care plans. Specifically, Resident #66 was not provided with leg rests on their wheelchair, resulting in unsupported feet dangling for extended periods, and Resident #6 was not assessed or monitored after spilling coffee on themselves.

Citations (1)
F 0684: The facility did not provide Resident #66 with leg rests on their wheelchair, causing their feet to dangle unsupported approximately six inches from the floor for extended periods. Resident #6 was not assessed or monitored after spilling coffee on themselves, and no documentation of skin assessment was found.
Report Facts
Residents reviewed for quality of care: 7 Residents affected: 2 Observation duration: 3 Observation duration: 2.5

Employees mentioned
NameTitleContext
LPN #1Licensed Practical NurseMentioned in relation to lack of awareness about Resident #6 coffee spill
CNA #1Certified Nursing AssistantObserved Resident #66 and provided statements about wheelchair leg rests
CNA #2Certified Nursing AssistantProvided statements about Resident #66 care and wheelchair leg rests
OT #1Occupational TherapistProvided information about Resident #66 foot pedals and positioning
OT #2Occupational TherapistResponsible for wheelchair positioning and screening of residents
RN #1Registered NurseExpected CNAs to follow wheelchair care plan recommendations for Resident #66
RN Unit Manager #3Registered Nurse Unit ManagerCommented on usual documentation practices for resident spills
DONDirector of NursingDiscussed expectations for wheelchair care and response to coffee spill incident

Inspection Report — Jan 14, 2022

Routine
Citations: 3 Date: Jan 14, 2022

Visit Reason
The inspection was a standard survey conducted to assess compliance with regulatory requirements related to resident care, medication storage, equipment safety, and abuse reporting.

Findings
The facility failed to timely report suspected abuse related to a resident's facial bruising, did not ensure medication storage cabinets were locked and secure, and did not maintain essential shower equipment with required vacuum breakers to prevent backflow.

Citations (3)
F 0609: The facility did not ensure timely reporting of suspected abuse for Resident #74 with facial bruising, failing to notify supervisors or initiate required assessments and investigations.
F 0761: The facility did not store all drugs and biologicals in locked compartments; medication cabinets in common areas were observed unlocked and unattended with accessible medications.
F 0908: The facility did not maintain essential shower equipment safely; eight of eleven tub/shower rooms lacked vacuum breakers on hand-spray wands, risking backflow contamination.
Report Facts
Medication bottles: 21 Medication bottles: 2 Tub/shower rooms: 8 Tub/shower rooms: 11

Employees mentioned
NameTitleContext
Director of NursingExpected reporting and investigation of resident bruising
Registered Nurse (RN) #4Had keys to medication cabinet and acknowledged it should be locked
Licensed Practical Nurse (LPN) #4Observed bruise but did not report or document it
Certified Nursing Assistant (CNA) #6Observed bruise and reported it to LPN #4
Assistant Director of Nursing (RN #7)Stated medication cabinets should always be locked
Pharmacy ConsultantExpected medication cabinets to be securely locked
Director of Plant OperationsReported no vacuum breakers on shower hoses and explained hose lengths

Inspection Report — May 9, 2019

Routine
Citations: 3 Date: May 9, 2019

Visit Reason
The inspection was a standard routine survey conducted to assess compliance with regulatory requirements related to resident care plans, feeding tube management, and equipment maintenance.

Findings
The facility failed to provide written baseline care plans to residents or their representatives within 48 hours of admission, did not ensure correct tube feeding formula administration for one resident, and did not maintain washing machines in safe and sanitary condition with black debris and mildew odors observed in multiple machines.

Citations (3)
F 0655: The facility did not provide a written summary of baseline care plans including initial goals, medications, and treatments to residents or their representatives within 48 hours of admission.
F 0693: The facility failed to provide the correct tube feeding formula as ordered for one resident, resulting in administration of the wrong formula.
F 0908: The facility did not maintain washing machines in safe operating condition; multiple machines had black debris on door gaskets and mildew odors.
Report Facts
Residents affected: 17 Residents affected: 1 Washing machines reviewed: 15 Washing machines with issues: 10

Employees mentioned
NameTitleContext
Director of Social WorkInterviewed regarding baseline care plan process and documentation
Registered Nurse (RN) MDS NurseInterviewed about admission care plan completion and notification process
Director of Nursing (DON)Interviewed about baseline care plan process and family notification
Registered Nurse (RN #5) Unit ManagerInterviewed about care plan initiation and family notification
AdministratorInterviewed about responsibility for baseline care plans and process formalization
Registered Nurse (RN #6) Neighborhood ManagerInterviewed about initial care plan completion and family notification
Licensed Practical Nurse (LPN #3)Interviewed about initial care plan and posting on resident door
Registered Nurse (RN) Unit Manager #4Observed feeding tube formula error and interviewed about formula changes
Licensed Practical Nurse (LPN #5)Interviewed about hanging wrong feeding tube formula
Licensed Practical Nurse (LPN #6)Interviewed about feeding tube formula handling
Registered Nurse (RN #5)Interviewed about washing machine use and observations
Licensed Practical Nurse (LPN #1)Interviewed about washing machine use and maintenance responsibility
Certified Nurse Aide (CNA #2)Interviewed about washing machine use and maintenance responsibility
Certified Nurse Aide (CNA #3)Interviewed about washing machine use and maintenance responsibility
Certified Nurse Aide (CNA #4)Interviewed about washing machine use and cleaning
Homemaker #4Interviewed about washing machine use and cleaning
Certified Nurse Aide (CNA #1)Interviewed about washing machine use and maintenance responsibility
Homemaker #1Interviewed about washing machine use
RN Infection PreventionistInterviewed about expectations for washing machine cleanliness
Facilities DirectorInterviewed about washing machine maintenance and staff education

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