Beacon Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care and services were provided for two of three sampled residents (Residents 1 & 2) when:a. Resident 1's ceftriaxone (an antibiotic medication used to treat urinary tract infections [UTI- an infection in the bladder/urinary tract]) order did not indicate the accurate reason for use.b. Resident 2's urinalysis (UA-a laboratory test that checks urine for signs of infection) and urine culture (a laboratory test that checks urine for bacteria) orders were not transcribed (written/ordered) and implemented as directed by the medical doctor (MD). These failures resulted in Resident 2 not receiving ordered laboratory tests and had the potential for Residents 1 and 2's medical needs not being addressed, posing a serious risk to the residents' overall health.

Inspectors wroteBased on interview and record review, the facility failed to provide laboratory services for one of three sampled residents (Resident 2) when the facility failed to send a urinalysis (UA-a laboratory test that checks urine for signs of infection) and urine culture (a laboratory test that checks urine for bacteria) to be tested as ordered by the medical doctor (MD) for Resident 2. This failure resulted in Resident 2's urine not being tested and had the potential to result in the delay of necessary care and services potentially leading to sepsis (a life-threatening blood infection).

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1) when Resident 1's discharge assessment (DA-a final evaluation conducted by healthcare workers before a resident leaves the facility) was not completed. This failure resulted in incomplete medical records for Resident 1 and had the potential for Resident 1 to receive inappropriate care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample resident (Resident 1) was provided with the Bed Hold Notification Form (BHNF) upon transfer to the General Acute Care Hospital (GACH) on [DATE]. This deficient practice resulted in Resident 1 not being able to readmit back to the facility upon discharge from GACH May of 2026. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pressure ulcer stage 4 (a severe, full-thickness wound where tissue loss exposes underlying bone, muscle, tendons, or ligaments) and chronic inflammatory demyelinating polyneuropathy (CIDP- a rare autoimmune disorder where the immune system attacks the myelin sheaths [the protective coating of nerves] in the peripheral nervous system). [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly notify one of five sampled residents' (Resident 1's) doctor of a change in condition in accordance with the facility's policy and procedure (P&P) titled, Acute Condition Changes - Clinical Protocol, when:a. Resident 1's doctor (DR 2) was not promptly informed of Resident 1's signs and symptoms (S&S) of a urinary tract infection (UTI- an infection in the bladder/urinary tract) which started on [DATE] at 12:00 PM.b. DR 2 was not promptly informed of an increase in size of Resident 1's right and left leg edema (swelling caused by too much fluid trapped in the body's tissues) which started on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical record for three of five sampled residents (Resident 1, Resident 2, and Resident 3) when:1. On [DATE], Licensed Vocational Nurse (LVN) 4 inaccurately documented that Resident 1 did not have any edema (swelling caused by too much fluid trapped in the body's tissues).2. Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated [DATE], inaccurately indicated Resident 1 did not have edema.3. Resident 1's, Resident 2's, and Resident 3's medical record did not contain documentation that the residents were turned and repositioned every two hours in accordance with the residents' care plans. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS, a resident assessment tool) was accurate for one of five sampled residents (Resident 1) when Resident 1's MDS, dated [DATE], incorrectly indicated Resident 1 did not have any pressure ulcer/injury pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) upon discharge from the facility on 2/3/2026. [...]

Inspectors wroteBased on interview and record review, the Wound Care Specialist (WCS) inaccurately diagnosed on e of five sampled resident's (Resident 1's) pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) on the left fifth toe as a diabetic wound (diabetic ulcer, an open sore or wound on a person with diabetes, most commonly on the foot, caused by nerve damage [neuropathy] and poor circulation). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent one of five sampled residents (Resident 1) from developing a pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) when:a. Licensed Vocational Nurse (LVN) 4 failed to document a skin assessment on Resident 1 upon Resident 1's admission to the facility on 1/8/2026.b. Resident 1's bed was too short for Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify, one of one sampled resident's (Resident 8), physician (Physician 1) of Resident 8's weight changes on 9/1/2025 and 10/7/2025. This deficient practice had the potential to result in serious health complications to Resident 8 due to the lack of notification to Physician 1 and delayed implementation of interventions.

Inspectors wroteBased on observation, interview, and record review the facility failed to effectively assess one of one sampled resident's (Resident 29) characteristics of pain as indicated in the facility's policy and procedure (P&P) titled, Pain Assessment. This deficient practice had the potential to result in ineffective pain management, unnecessary discomfort and pain to Resident 29, and had the potential to affect Resident 29's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a thermometer was easily visible inside one of two refrigerators (Reach-in Refrigerator 2) in the facility's kitchen on 1/14/2026 as indicated in the facility's Policy and Procedure (P&P) titled, Procedure for Refrigerated Storage. This failure had the potential to result in the food stored inside Reach-in Refrigerator 2 not being maintained at proper temperatures and the potential to result in foodborne illness (an illness caused by eating contaminated food) to the residents consuming the food.

Inspectors wroteBased on observation and record review, the facility failed to ensure two of two sampled residents (Residents 7 and 15), were provided privacy curtains for the residents during incontinence care. These failures prevented Residents 7 and 15 from having privacy during care and had the potential to affect Residents 7 and 15's dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food handling service. During initial tour of the kitchen on 11/15/24, one open bag of frozen patties and one open frozen bag of eggrolls were unlabeled and undated in the facility freezer for one of one facility kitchen. This deficient practice had the potential to result in foodborne illnesses (illness caused by consuming contaminated food or beverages) to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurately completed for one of one sampled resident (Residents 99). Resident 99's MDS did not accurately reflect the resident's hearing abilities and limitations. This deficient practice had the potential for Resident 99 not to receive necessary treatment and/or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 99) received necessary treatment to prevent a decline, maintain or improve Resident 99's hearing abilities and quality of life. This deficient practice had the potential to result in Resident 99's decline in hearing, social interaction, and overall quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly apply a pressure relief boot (PRB) for one of three sampled residents (Resident 2) who had a pressure ulcer (localized injury to the skin and or underlying tissue usually over a bony prominence because of pressure or pressure in combination with shear and/or friction) on Resident 2's right heel. This failure had the potential to worsen Resident 2's pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 100) who received oxygen therapy, was provided safety in accordance with the facility's Policy and Procedure (P&P) on oxygen administration and professional standards of practice by ensuring a cautionary sign was posted on the resident's door indicating oxygen was in use. This deficient practice placed Resident 100's safety at risk regarding oxygen use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly assess resident's pain for one of one sampled resident (Resident 23) during a medication pass observation. This deficient practice had the potential to negatively affect Resident 23's physical comfort and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to post actual worked nursing hours at the start of each shift for one of three dates (11/14/2024) according to the facility's policy and procedure (P&P) titled, Consumer Information, revised 1/18/2023. This failure had the potential to result inaccurately reflecting the actual nurses providing direct care to the residents.

Inspectors wroteBased on interview and record review the facility failed to ensure one of five sampled residents (Resident 149) was reviewed for the McGeer's criteria (criteria used for retrospectively counting true infections. To meet the criteria for definitive infection, more diagnostic information [e.g., positive laboratory tests] is often necessary) when Resident 149 was receiving antibiotics (medications that fight bacterial infections). This deficient practice had the potential for Resident 149 from receiving unnecessary antibiotic.

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare food by method that conserved flavor, texture, and appearance by servicing at a safe temperature. During a tray-line observation, soup temperature from the requested test tray measured at 120 degrees Fahrenheit (F, a scale of temperature) for one of one facility kitchen. This deficient practice had the potential to result in meal dissatisfaction, decreased intake, and placed the residents at risk for unplanned weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2), who signed an Arbitration Agreement (Binding Arbitration Agreement), had the capacity to understand and make an informed decision. This failure had the potential to result in Resident 2 to not be able to make an informed decision and/or Resident 2's rights to be denied.

Inspectors wroteBased on interview and record review, the facility failed to ensure complete documentation regarding discharge planning was done for one of three sampled residents (Resident 1). This deficient practice had the potential to not provide full information regarding the discharge plans that were discussed for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Resident Access to Records, by not providing a copy of medical records within the policy ' s time frame for one of three sampled residents' (Resident 1) responsible party (RP, a person responsible for paying resident's bills or making healthcare decisions). This failure resulted in Resident 1 ' s RP ' s rights being violated when the facility did not provide access to Resident 1 ' s medical records within 48 hours. from 10/30/23 to 12/8/23 (total of 39 days).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement care plans (CP) that met the needs of two of two sampled residents (Residents 17 and 32) as indicated in the facility's policy and procedure, titled, Care Plans, Comprehensive Person-Centered. a. The facility did not follow interventions inidicated in Resident 17's Pressure Injury CP. Resident 17 was not repositioned every two hours as indicated in Resident 17's CP. b. b. Resident 32's CP for communication skills did not include appropriate interventions that addressed Resident 32's problem areas. Resident 32 did not speak English only spoke Thai and Resident 32 could not see the communication board indicated in the CP due to glaucoma (a group of eye conditions that can cause blindness). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 32), who had limited English proficiency (LEP), received translation support and services by the facility according to the facility's policy and procedure (PP) titled, Translation and/or interpretation of Facility Services, by failing to when Resident 32's primary language was Thai (language of Thailand) and the facility spoke English to Resident 32. This failure had the potential in Resident 32 not to be able to communicate basic needs and had the potential to result in Resident 32 to suffer a physcial and psychosocial decline.

Inspectors wroteBased on interview and record review, the facility failed to ensure in-service training was completed for one of one Certified Nursing Assistants (CNA 2). This failure had the potential to result in the residents with diagnoses of Dementia (a decline in mental ability) to not receive proper care and services and result in a decline in physical health.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS, an assessment and screening tool) was coded correctly for two of two sampled residents (Resident 36 and Resident 32). a. Resident 36 was discharged to home and the Minimum Data Set (MDS, an assessment and screening tool) dated 10/11/23 was coded as Resident 36 being discharged to the hospital. b. Resident 32's primary language was Thai and was documented as English in the MDS dated [DATE]. This failure resulted in inaccuracy of Resident 36 and 32's MDS clinical status and had the potential to result in both residents to not receive the necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety measures were implemented, for one of two sampled residents (Resident 26) and as indicated in the facility's policy and procedure (P&P), when Resident 26's bed pad alarm (device that alerts staff when a resident gets out of bed) was turned off. Resident 26 was at high risk for falls and had a history of multiple falls. This failure had the potential to result in injury and a physical decline to Resident 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided to one of two sampled Residents (Resident 29). Resident 29, who had experienced weight loss, did not receive his supplement of ice cream with his lunch tray as ordered by the physician. This failure had the potential to result in further weight loss to Resident 29.

Inspectors wroteBased on interview and record review, the facility failed to act upon the pharmacist medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication.) recommendation to not use insulin sliding scale (a sliding scale varies the dose of insulin based on blood glucose level. The higher the blood glucose the more insulin to take) for one of five sampled residents (Resident 14). This deficient practice had the potential for the resident receiving unnecessary mediations and not maintaining the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard a Lantus insulin (long-acting medication used to regulate blood sugar levels) vial, for one of four sampled residents (Resident 18), during medication administration observation and according to the facility's policies and procedures (P&P). This failure had the potential to result in Resident 18 to experience adverse reactions (any unexpected or dangerous reaction to a medication) due to the administration of the expired medication.

Inspectors wroteBased on observation, interview and, record review, the facility failed to prepare meals that met resident preferences and allergy status for one of four sampled residents (Resident 2)as inicated in the facility's policy and procedure (P&P), titled, Nutrition Care. This failure had the potential to affect Resident 2's dietary intake and result in Resident 2 to experience an allergic response and cause a physical decline to Resident 2.

Inspectors wroteBased on observation and interview, the facility failed to ensure sanitary practices were followed by one of three sampled staff (Dietary Aid, DA 1). On 11/17/23, DA 1 did not wear a hairnet (netting over the hair to keep hair from contacting exposed food, clean equipment and utensils) during the handling and preparation of food. This failure had the potential to result in foodborne illnesses (illness caused by food contaminated with bacteria) from pathogens (organism that cause disease) that could have been on the hair and land on exposed food fed to residents who ate food orally (by mouth).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices for one of four sample residents (Resident 19) when Resident 19's urine drainage bag (urinary bag, attaches to a catheter [tube] that is inside your bladder to collect urine.) was observed touching the floor on 11/17/23, as indicated by the facility's policy and procedure P&P titled, Catheter Care, Urinary. This failure had the potential to result in a urinary tract infection (UTI, an infection in any part of the urinary system.) to Resident 19.