Inspection Reports for
Beechwood Homes
2235 Millersport Highway, Getzville, NY, 14068
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jul 3, 2025
Visit Reason
One isolated Level 2 deficiency related to medication errors was identified and corrected by August 26, 2025.
Findings
One isolated Level 2 deficiency related to medication errors was identified and corrected by August 26, 2025.
Deficiencies (1)
Residents are free of significant med errors
Inspection Report
Complaint Investigation
Deficiencies: 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.
Deficiencies (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
Routine
Deficiencies: 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.
Deficiencies (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
Complaint Investigation
Capacity: 60
Deficiencies: 14
Date: Nov 8, 2023
Visit Reason
Multiple Level 2 deficiencies found in quality of care and life safety code including aisle widths, corridor doors, electrical systems, exit signage, fire alarm system, gas equipment storage, hazardous areas, illumination, maintenance, means of egress, sprinkler system, smoke barriers, and travel distance to exits. All corrected by early 2024.
Findings
Multiple Level 2 deficiencies found in quality of care and life safety code including aisle widths, corridor doors, electrical systems, exit signage, fire alarm system, gas equipment storage, hazardous areas, illumination, maintenance, means of egress, sprinkler system, smoke barriers, and travel distance to exits. All corrected by early 2024.
Deficiencies (14)
Quality of care
Aisle, corridor, or ramp width
Corridor - doors
Electrical systems - essential electric syste
Exit signage
Fire alarm system - installation
Gas equipment - cylinder and container storag
Hazardous areas - enclosure
Illumination of means of egress
Maintenance, inspection & testing - doors
Means of egress - general
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Travel distance to exits
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Jan 14, 2022
Visit Reason
Level 1 and Level 2 deficiencies identified in essential equipment, drug labeling/storage, reporting of alleged violations, and multiple life safety code issues including aisle widths, hand rub dispensers, corridor doors, fire alarm system, hazardous areas, and means of egress. All corrected by March 11, 2022.
Findings
Level 1 and Level 2 deficiencies identified in essential equipment, drug labeling/storage, reporting of alleged violations, and multiple life safety code issues including aisle widths, hand rub dispensers, corridor doors, fire alarm system, hazardous areas, and means of egress. All corrected by March 11, 2022.
Deficiencies (9)
Essential equipment, safe operating condition
Label/store drugs and biologicals
Reporting of alleged violations
Aisle, corridor, or ramp width
Alcohol based hand rub dispenser (abhr)
Corridor - doors
Fire alarm system - testing and maintenance
Hazardous areas - enclosure
Means of egress - general
Inspection Report
Routine
Deficiencies: 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.
Deficiencies (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
Routine
Deficiencies: 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.
Deficiencies (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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