Inspection Reports for
Beechwood Homes
2235 Millersport Highway, Getzville, NY, 14068
Back to Facility ProfileInspection 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
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Named as the nurse who administered the wrong medications | |
| Director of Nursing | Provided statements regarding the medication error and its significance | |
| Medical Director | Notified 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
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Mentioned in relation to lack of awareness about Resident #6 coffee spill |
| CNA #1 | Certified Nursing Assistant | Observed Resident #66 and provided statements about wheelchair leg rests |
| CNA #2 | Certified Nursing Assistant | Provided statements about Resident #66 care and wheelchair leg rests |
| OT #1 | Occupational Therapist | Provided information about Resident #66 foot pedals and positioning |
| OT #2 | Occupational Therapist | Responsible for wheelchair positioning and screening of residents |
| RN #1 | Registered Nurse | Expected CNAs to follow wheelchair care plan recommendations for Resident #66 |
| RN Unit Manager #3 | Registered Nurse Unit Manager | Commented on usual documentation practices for resident spills |
| DON | Director of Nursing | Discussed 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
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Expected reporting and investigation of resident bruising | |
| Registered Nurse (RN) #4 | Had keys to medication cabinet and acknowledged it should be locked | |
| Licensed Practical Nurse (LPN) #4 | Observed bruise but did not report or document it | |
| Certified Nursing Assistant (CNA) #6 | Observed bruise and reported it to LPN #4 | |
| Assistant Director of Nursing (RN #7) | Stated medication cabinets should always be locked | |
| Pharmacy Consultant | Expected medication cabinets to be securely locked | |
| Director of Plant Operations | Reported 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
| Name | Title | Context |
|---|---|---|
| Director of Social Work | Interviewed regarding baseline care plan process and documentation | |
| Registered Nurse (RN) MDS Nurse | Interviewed 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 Manager | Interviewed about care plan initiation and family notification | |
| Administrator | Interviewed about responsibility for baseline care plans and process formalization | |
| Registered Nurse (RN #6) Neighborhood Manager | Interviewed 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 #4 | Observed 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 #4 | Interviewed about washing machine use and cleaning | |
| Certified Nurse Aide (CNA #1) | Interviewed about washing machine use and maintenance responsibility | |
| Homemaker #1 | Interviewed about washing machine use | |
| RN Infection Preventionist | Interviewed about expectations for washing machine cleanliness | |
| Facilities Director | Interviewed about washing machine maintenance and staff education |
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