Beaconshire Nursing Centre

Inspectors wroteBased on observation, interview, and record review the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain general cleanliness and repair of the premises including plumbing, handrails, and bathroom surfaces. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living for all residents. Findings Include: On 04/01/2026 at 8:26 AM observed a four-inch pipe running along the ceiling between two dryers in the laundry room. Insulation around the pipe was observed peeling and with loose fibers exposed. An interview with Housekeeping Manager (HM) E at this time found they were unsure of what the pipe was and speculated it was an old water line. On 04/01/2026 at 8:32 AM observed a bucket beneath the handsink drain line in the laundry room. A pool of water was observed in the bucket. HM E indicated they would let maintenance know about the leak. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet per Resident in multiple resident bedrooms, affecting five Resident rooms (111, 115, 119, 219, and 231).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was assessed to self-administer medications for one (R71) of one reviewed for self-administration of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of practice for medication administration for one resident (R71) of one resident reviewed for medication administration.

Inspectors wroteThe facility failed to implement interventions for residents at-risk for unplanned weight loss for one (R2) of six residents reviewed for nutrition status.

Inspectors wroteThis deficient practice pertains to 1232811. Based on observation, interview, and record review the facility failed to don appropriate personal protective equipment (PPE) for one resident (R407) of three resident reviewed for enhanced-barrier precautions resulting in the potential for the transmission of infectious organisms.

Inspectors wroteThis citation pertains to intake MI00152716. Based on observation, interview and record review, the facility failed to ensure a call light was available and in place for 6 residents (R503, R508, R509, R510, R511, and R512) of 91 residing in the facility resulting in the potential for unmet needs, harm or serious injury.

Inspectors wroteThis citation pertains in intake: MI00153399 and MI00153424. Based on observation, interview, and record review the facility failed to ensure staff reported a bruise of unknown origin for one (R503) of five residents reviewed for abuse, resulting in an unreported incident of potential abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to (1) ensure desserts delivered to three unidentified residents were properly covered and (2) failed to maintain the ice machine in a clean and sanitary condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly dispose of refuse and maintain cleanliness of garbage and refuse areas resulting in the potential harborage of pests. This deficient practice has the potential to affect all 92 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe and sanitary laundry room and clean linen closet resulting in the potential for the spread of infection and disease transmission to residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the three-compartment sink was properly air gapped, resulting in this food equipment not being protected against contamination from sewage or other sources of contamination.

Inspectors wroteOn 1/27/25 at 11:50 AM, a computer on a medication cart was observed opened to R28's Electronic Medical Record, (EMR). Social Worker, (SW) Q was coming down the hall and stopped when directed to look at the resident's information on the computer screen. SW Q alerted the nurse that was coming down the hall that the computer was left opened. SW Q was then queried about R28's EMR being opened in the hallway so anyone walking by could see it and said it was a violation of the resident's privacy. On 1/27/25 at 11:55 AM, License Practical Nurse, (LPN) I was interviewed about leaving R28's EMR open and said that was not the normal computer they use. LPN I said they understand R28's EMR should not have been left open and they know it is a violation of R28's privacy. On 1/29/25 at 12:00 PM, the DON was interviewed about R28's EMR left opened. The DON said it was a violation of HIPPA. [...]

Inspectors wroteBased on observation and interview the facility failed to make timely repairs for the residents residing in rooms [ROOM NUMBER] resulting in unsafe, unhomelike, and dysfunctional paper towel dispenser.

Inspectors wroteBased on observation and record review, the facility failed to provide at least 80 square feet per resident for five rooms (#'s 111, 115, 119, 219, and 231) resulting in the potential for resident dissatisfaction with their living space and not having adequate space available for care.

Inspectors wroteThis citation pertains to intake MI00149479. Based on observation, interview, and record review, the facility failed to provide adequate supervision for one resident (R401) on oxygen with a known history of unsupervised smoking and noncompliance with smoking policy out of four residents reviewed for safety with smoking, which led to a fire resulting in a 2nd degree facial burns((an injury that damages the outer layer of skin (epidermis) and part of the underlying layer(dermis)) and hospitalization in the burn unit. The Immediate Jeopardy began on 1/10/25 when an untrained facility staff (sitter) failed to properly supervise R401during a smoke break leading to the R401 obtaining a lighter and cigarette. Later, R401 (while inhaling oxygen through a nasal canula) attempted to smoke in his bathroom unsupervised and lit his face on fire. [...]

Inspectors wroteThis citation pertains to intake MI00149479. Based on observation, interview, and record review, the facility failed to ensure staff reported an injury related to fire to the abuse coordinator for one resident (R401) out of four residents reviewed for accidents, resulting in an unreported incident of potential neglect.

Inspectors wroteThis citation pertains to intake MI00149479. Based on observation, interview, and record review the facility failed to maintain complete and accurate medical records for one resident (R401) out of three residents reviewed for accidents, resulting in the absence of accurate documentation of R401's facial burns. Findings Include: On 1/13/2025 at 11:34 AM the State Agency received a complaint that on 11/10/2025 R401 lit a cigarette while on oxygen and lit his face on fire. On 1/15/2025 at 10:50 AM R401's guardian A was interviewed and said a staff member from the facility called to notify him on 1/11/25 or 1/12/25 that R401 lit his face on fire smoking again in is bathroom and was at hospital C for the treatment of facial burns. On 1/21/24 at 2:00 PM R401 was interviewed at Hospital L. R401 was observed as an African American male with dark colored skin. [...]

Inspectors wroteThis citation pertains to intake MI00146029. Based on interview, and record review, the facility failed to prevent misappropriation of resident medication for one resident (R101) of three reviewed for misappropriation, resulting in resident experiencing pain and the potential for misappropriation to continue.

Inspectors wroteThis citation pertains to intake MI00146029. Based on interview and record review, the facility failed to report allegations of misappropriation for one (R101) of three residents reviewed for misappropriation.

Inspectors wroteThis Citation Pertains to Intake MI00146029. Based on observation, interview and record review the facility failed to follow the procedure for reconciling controlled substances (drugs that have high potential for abuse and misappropriation) for one (R102) resident from one of four medication carts reviewed for medication storage, resulting in the potential for drug diversion to go undetected.

Inspectors wroteThis citation pertains to Intakes MI001444419, MI00145071, and MI00145216. Based on interview and record review the facility failed to provide adequate supervision for one resident (R402) of three residents reviewed for elopements, resulting in a moderately cognitively impaired resident with behavior issues exiting a second-floor window and falling to the ground causing a left tension pneumothorax (collapsed lung), multiple acute rib fractures, left clavicle and scapulae fractures, and thoracic vertebrae fractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely secure the second-floor dining room windows and resident room [ROOM NUMBER] bathroom window from fully opening affecting all second floor residents who utilize the dining room and R405, resulting in the potential for additional unauthorized resident egress via the windows. On 7/23/24 at 9:05 AM in an observation with Licensed Practical Nurse/Unit Manager (LPN) B the bathroom window in room [ROOM NUMBER] top pane did not lock and was able to fully open. LPN B said the window should lock and should not open all the way. It is not safe for residents because they can get out the window. [...]

Inspectors wroteBased on interview and record review, the facility failed to (1) timely notify the guardian of an acute change in condition and (2) obtain consent and notify the guardian for a room change to a lockdown unit for one resident (R402).

Inspectors wroteThis citation pertains to intake MI00144419. Based on interview and record review, the facility failed to immediately report an elopement resulting in injury to the State Agency (SA) for one (R402) of three residents reviewed for elopement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide comfortable room temperatures for two residents (R302 and R303) out of three residents reviewed for increased environment temperature, resulting in residents discomfort and decrease in quality of life within the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure the reason for discharge or a discharge summary was documented in the medical record for two of two residents (R501 and R502) reviewed for discharges/transfers.

Inspectors wroteBased on interview and record review, the facility failed to notify the Ombudsman of the reason for transfer to another facility for two residents (R501and R502) reviewed for discharge/transfers.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to effectively clean and maintain the physical plant in a sanitary manner, resulting in the increased likelihood for bacterial harborage and growth, and an unsafe, environment for residents, the public and staff. This deficient practice had the potential to affect all 82 residents who resided in the facility at the time of survey.

Inspectors wroteThis citation pertains to MI00139177 and MI00139604. Based on interview and record review the facility failed to prevent staff to resident verbal abuse for two residents (R38 and R235) of 16 residents reviewed for abuse, resulting in staff members abusing residents verbally and the potential for decreased self-esteem. Findings Include: Record review revealed facility's Nursing Home Administrator (NHA) reported to the State Agency an allegation of abuse on 9/3/23 at 7:11 PM. Incident summary documented that facility employee Sitter I was observed by LPN J using profanity toward R38. LPN J reported that Sitter I said, Why you touch my f*&King food, and then said, You got me f*$ked up . Record review of Abuse Investigation Statement dated on 9/5/23 by LPN J documented the following: 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plans for two (R17 and R22) of 27 residents reviewed for care planning, resulting in unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide 80 square feet per resident in five of 49 rooms in the facility (rooms 111, 115, 119, 219 and 231) resulting in the potential for inadequate living space.