Beaumont Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 Residents (Resident #16 and Resident #5) reviewed for catheter care. The facility failed to assess complications and their causes and maintain a record of any catheter (thin, flexible tube inserted into the body to drain fluids) related problems for Resident #16. The facility failed to assess and ensure appropriate treatment and services were provided including reporting and maintaining a record of any catheter related problems for Resident #5. These failures could place residents who require indwelling catheters at risk for catheter blockage, fistula (abnormal tunnel connecting two body parts) formation, or infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 6.45%, based on two errors out of 31 opportunities, which involved 2 of 7 residents (Resident #60, and #66) and 2 of 4 staff (LVN A, and RN B) reviewed for medication error., in that: 1. The facility failed to ensure LVN A did not administer an incorrect dose of Calcium to Resident #66 on 07/07/2026 during a medication pass. 2. The facility failed to ensure RN B did not administer a dose of sliding scale Humalog insulin (used to treat diabetes) from an insulin pen labeled do not use after 06/29/2026 on 07/07/2026, to Resident #60 during a medication pass. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (Nurse Back of Hall 200) reviewed for medication storage. The facility failed to ensure medications were not stored on top of the medication cart. This failure could place residents at risk of misappropriation of medications, adverse reactions by ingesting medication that did not belong to them, and not receiving therapeutic effects of medication.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 6 residents (Resident #68) reviewed for infection control. The facility failed to ensure CNA D and CNA E wore a gown during high contact activities (bed bath) for Resident #68, who had enhanced barrier precautions in place. This failure could place residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 2 of 33 beds (Residents #1 and #2) reviewed for essential equipment. The facility did not ensure the 2 of 33 (Residents #1 and #2) resident beds on Hall 100 had footboards and were in safe operating condition. This failure could place residents at risk of injury and patient care equipment not in safe operating condition.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide proper treatment and services to prevent complications of enteral feeding for one of two residents (Residents #1) reviewed for feeding tubes. The facility failed to ensure staff followed physician's orders for 45 ml of water to be flushed every hour for Resident #1, while the tube feeding was running. These failures could place residents at risk of tube obstruction and a decrease in hydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 4 of 8 residents (Residents # 12, # 22, #210 and #259) reviewed for respiratory therapy. The facility failed to ensure Residents #12 and #22 had a physician order for oxygen and was care planned. The facility failed to ensure Resident #210 was set on 3 LPM per oxygen concentrator (machine that takes air from your surroundings and extracts oxygen and filters it into purified oxygen to breathe). The facility failed to keep the oxygen concentrator filter clean for Resident #259. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure all staff wore hair restraints and restrained all of their hair while plating the food. (05/12/25) This failure could place residents who ate meals prepared in the kitchen at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for residents that included their specific needs as identified in each resident's comprehensive assessment for 2 of 10 residents (Residents #12 and #22) reviewed for person-centered care plans. Residents #12 and #22 did not have care plans developed for oxygen therapy. This failure could place residents at risk of not receiving proper care or inadequate oxygen support which could result in diminished physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 3 of 7 residents (Residents #9, #47, and #104) reviewed for unnecessary medications. The facility did not have appropriate indications for medications based on Resident #9's, #47's, and #104's diagnoses. This failure could place residents at risk of complications related to receiving unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 3 residents reviewed for unnecessary psychotropic drugs. (Resident #47) The facility failed to ensure Resident #47 had an appropriate diagnosis or adequate indication for the use of Trazadone (an antidepressant used to treat depression) and Zoloft (an antidepressant used to treat depression). This failure could place residents at risk for receiving unnecessary medication, having unnecessary medication side effects, and a decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 4 residents reviewed for resident rights. (Resident #5) The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Resident #5. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, and possibly being brought back to life in an unaware and unresponsive state.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 1 resident (Resident #42) reviewed for enteral feeding. LVN A failed to verify placement of Resident #42's G-tube by checking for residual (fluid and contents that remain in the stomach) before enteral administration of water and medications. This failure could place residents receiving enteral nutrition and medications at increased risk of not receiving proper nutrition, infection, and aspiration.