Beaumont Nursing and Rehabilitation

Inspectors wroteBased on interview and record review the facility failed to have qualified professional(s) who was qualified as a therapeutic recreation specialist or an activities professional who was licensed or registered by the State to for 1 of 1 facility reviewed for qualifications of activity professionals. The facility failed to ensure a qualified Activities Professional was in place to direct their activities program for the previous 12 weeks. There was no qualified Activity Director in place from 5/12/2026 and as of 08/12/2026 (date of survey exit). This deficient practice could place residents at risk of not receiving approaches that were individualized to match the skills, abilities, and interests/preferences of each resident for activities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistently with professional standards of practice for 1 of 5 residents reviewed for respiratory care. (Resident #56)The facility failed to ensure Resident #56 received bi-pap for 3 days and not obtaining parameters for the bi-pap machine and oxygen levels to be maintained. This failure could place residents at risk of illness, respiratory complications, and accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 17 residents (Resident #56) reviewed for baseline care plans. The facility failed to ensure Resident #56's baseline care plan was completed within 48 hours of admission on to include oxygen administration and bi-pap (a non-invasive medical device that helps people breathe by delivering two alternating pressure levels a higher pressure when you breath in and lower pressure when you breathe out) machine use. This failure could place residents at risk of not having needs met

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #11) of 17 residents reviewed for care plans. The facility failed to care plan Resident #11's external male catheter with urine collection system (uses suction to pull urine through tubing to the connected collection canister) when he admitted on [DATE] with an urine collection system. This failure could affect residents by placing them at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interviews, and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 of 17 residents ( Resident #11) reviewed for activities. The facility failed to provide Resident #11 in room activities since his admission on [DATE]. This failure could place residents at risk for boredom, depression, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the appropriate care and services to prevent urinary tract infections to the extent possible for 1 of 1 resident (Resident #11) reviewed for external catheters. The facility failed to ensure physician orders for the external male catheter with a urine collection system (used suction to pull urine through tubing to the connected collection canister) for Resident #11 when he admitted on [DATE]. This failure could place residents at risk of not receiving care and services and could cause decline in conditions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 17 residents (Resident #11) reviewed for storage and labeling of medications. The facility failed to ensure Resident #11 did not have medications Neosporin and prescribed miconazole 2% (anti-fungal cream) at the bedside. These failures could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications.

Inspectors wroteBased on interviews and record review, the facility failed to provide required effective communications training for direct care staff for 1 of 23 (PT F) staff sampled for licensure and training. The facility failed to ensure that PT F had completed the mandatory effective communication training. This failure could place residents at risk of being cared for by untrained staff. Record review of personnel record for PT F indicated a hire date of 01/31/2025. Review of the facility's training log, undated, showed no evidence of effective communication training for PT F.Record review of the training log for the previous 12 months (08/12/2025 to 08/12/2026) provided by human resources department indicated no evidence that PT F completed effective communication training. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide required Quality Assurance Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program, for 1 of 23 (PT F) staff sampled for licensure and training. The facility failed to ensure that PT F had completed the mandatory QAPI training. This failure could place residents at risk of being cared for by untrained staff. Record review of personnel record for PT F indicated a hire date of 01/31/2025. Review of the facility's training log, undated, showed no evidence of QAPI training for PT F.Record review of the training log for the previous 12 months (08/12/2025 to 08/12/2026) provided by human resources department indicated no evidence that PT F completed QAPI training. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program, for 1 of 23 (PT F) staff sampled for licensure and training. The facility failed to ensure that PT F had completed the mandatory infection prevention and control program training. This failure could place residents at risk of being cared for by untrained staff. Record review of personnel record for PT F indicated a hire date of 01/31/2025. Review of the facility's training log, undated, showed no evidence of infection prevention and control program training for PT F.Record review of the training log for the previous 12 months (08/12/2025 to 08/12/2026) provided by human resources department indicated no evidence that PT F completed infection prevention and control program training. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide required Ethics training, for 1 of 23 (PT F) staff sampled for licensure and training. The facility failed to ensure that PT F had completed the mandatory Ethics training. This failure could place residents at risk of being cared for by untrained staff. Record review of personnel record for PT F indicated a hire date of 01/31/2025. Review of the facility's training log, undated, showed no evidence of ethics training for PT F.Record review of the training log for the previous 12 months (08/12/2025 to 08/12/2026) provided by human resources department indicated no evidence that PT F completed ethics training. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide required behavioral health training, for 1 of 23 (PT F) staff sampled for licensure and training. The facility failed to ensure that PT F had completed the required behavioral health training. This failure could place residents at risk of being cared for by untrained staff. Review of the facility's training log, undated, showed no evidence of training for behavioral health for PT F. Record review of personnel record for PT F indicated a hire date of 01/31/2025. Review of the facility's training log, undated, showed no evidence of behavioral health training for PT F.Record review of the training log for the previous 12 months (08/12/2025 to 08/12/2026) provided by human resources department indicated no evidence that PT F completed behavioral health training. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #1). The facility failed to provide adequate supervision for Resident #1, who resided on the secured unit due to high risk for elopement and history of elopement, from leaving the facility unsupervised on 11/24/2025. Resident #1 was found at a local hospital emergency room where he had been taken by local police. The facility was not aware that the resident was missing for approximately 1.5 hours until a family member and local police called facility staff about his whereabouts. The noncompliance was identified as PNC (past noncompliance). The IJ began on 11/24/2025 and ended on 11/25/2025. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteDuring an observation on 06/09/25 at 12:35PM the pureed food served in the facility was observed. On each puree tray there was a main plate with 3 foods including a brown ground meat, a white food, and a yellow food. The consistency of all three foods was mechanical soft. During an interview on 06/09/25 at 02:30 PM, [NAME] F said he made the puree this day. He said he was not trained on how to make the puree. He said he was not sure if there was a recipe for the puree. He said he did not follow a recipe for the puree this day. He said his puree usually comes out more like mashed potatoes. He said he was running behind today and he was in a hurry. He said the old Dietary Manager left about a month ago. He said the risk to the resident was possible choking. During an interview on 06/11/25 at 11:34 AM, the DON said she expected [NAME] F to have been trained to make puree foods. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the each resident received food prepared in a form to meet their individual needs for 4 of 4 residents (Residents #4, #31, #30, and #16) reviewed for pureed diet consistency. The facility failed to ensure Resident #4 was served a pureed diet as ordered by the physician. The facility failed to ensure Resident #31 was served a pureed diet as ordered by the physician. The facility failed to ensure Resident #30 was served a pureed diet as ordered by the physician. The facility failed to ensure Resident #16 was served a pureed diet as ordered by the physician. These failures could place residents at risk of choking, aspiration, and/or death.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. The facility failed to ensure all foods stored in the refrigerators were not kept past their expiration dates and did not contain mold. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove and dishwasher in the kitchen reviewed for food service in that: The facility did not ensure the gas stove was in working order. Two of six gas stove burners (left front and left back) did not light automatically, when the knob was turned, and all 6 burners had carbon buildup. The facility did not ensure the dishwasher was in working order. The temperature did not reach 120-140 degrees. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food and risk of food borne illnesses by the dishwasher not appropriately sanitizing dishes.

Inspectors wroteBased on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #31) of 16 residents reviewed for PASRR . The facility failed to refer Resident #31 for PASRR level II assessment, to the state-designated authority, upon receipt of a major depressive disorder recurrent severe diagnosis. These failures could place residents at risk of not receiving necessary care and/or services. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 2 of 8 residents (Resident #4 and Resident #13) reviewed for PASRR Level I screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #4. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Disorganized Schizophrenia) was present upon Resident #4's admission date on 01/15/21. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #13. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Schizophrenia) was present upon Resident #13's admission date on 02/02/24. [...]

Inspectors wroteBased on observations, interviews, 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 1 of 2 residents (Resident #37) reviewed for infection control. CNA T did not wash or sanitize her hands or change gloves while performing incontinent care for Resident #37. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents reviewed for accidents and supervision. (Resident #1) The facility failed to provide adequate supervision for Resident #1 who was assessed as a high risk for elopement. On 11/08/2024 he was allowed to sit on the front porch without supervision, and facility received a phone call from another resident's family member informing facility Resident #1 was at the end of the facility's exit driveway entering the residential roadway. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 11/02/2024 and ended on 11/08/2024. The facility had corrected the non-compliance before the survey began. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 2 of 5 employees (LVN O & LVN T) reviewed for develop and implement abuse policies. The facility failed to ensure the Administrator implemented the facility's abuse/neglect policy and procedure when she failed to document suspension timeframes and advise the employees of the outcomes of the investigation in the determination of disciplinary action and/or reinstatement. The facility failed to document suspension time frames and advise the employee of the investigation outcome when LVN O allegedly verbally abused Resident #2 on 10/14/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse were reported, immediately but not later than 2 hours after the allegation was made, if the events that cause the allegation involves abuse or results in serious bodily injury, to the State Survey Agency for 1 of 4 residents (Residents #2) reviewed for reporting allegations of abuse. The facility failed to report an allegation of abuse within 2 hours after LVN O allegedly verbally abused Resident #2 on 10/14/2024. The failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed investigate and report the findings of the investigation to the State Survey Agency within 5 working days of the incident for 1 of 4 residents (Residents #2) reviewed for abuse. The facility failed to investigate and submit the results of their investigation within 5 days after LVN O allegedly verbally abused Resident #2 on 10/14/2024. These failures could place residents at risk of abuse, physical harm, mental anguish and emotional distress.

Inspectors wroteBased on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #1) reviewed for hospice services. The facility failed to obtain Resident #1's hospice plan of care, nurse visit notes, and aide visit notes. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 5 residents (Resident #1) reviewed for discharge requirements. The facility failed to ensure Resident #1 was readmitted to the facility, after being treated at a behavior hospital. This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely and housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 10 out of 10 residents in the secure unit reviewed for environment. The facility failed to ensure housekeeping and maintenance services were provided for Resident #4. The facility failed to clean and lock an in-wall storage cabinet in Resident #4's room. The facility failed to ensure the air conditioning was working properly to provide comfortable and safe temperature levels for residents in the secure unit and failed to keep cabinets secured and clean. Temperatures in resident rooms were above 81 degrees F. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 4 (Resident #19, Resident #27, Resident #28, and Resident #198) of 7 residents reviewed for respiratory care. The facility failed to ensure there were cautionary and safety signs indicating the use of oxygen outside the resident's rooms where oxygen was used. These failures placed the residents at increased risk of injury due to fire hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control program to prevent the development and transmission of communicable diseases was implemented by the facility for 8 of 8 residents (Residents #8, #9, #10, #11, #12, #13, #17, and #18) and 13 of 13 staff (CNA J, MA K, CNA N, HSK O, LVN X, LDY P, CNA Q, CNA R, CNA S, CNA T, LVN U, CNA V, and LVN W) in the facility reviewed for infection control practices and transmission-based precautions. The facility failed to ensure facility staff (CNA J, MA K, CNA N and HSK O) wore appropriate PPE when entering COVID-19 (infectious disease caused by the SARS virus) positive residents' rooms. (Residents #8, #9 #10, #11, #12, and #13). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse of residents were reported immediately to the administrator and to HHSC within the 2-hour period for 8 of 11 residents (Resident #1, #2, #3, #4, #5, #6, #7, and #14) reviewed for abuse. The facility failed to ensure allegations of resident-to-resident altercations and resident and staff altercations were reported immediately to the administrator and to the State Agency no later than 2 hours after the incident occurred or was suspected. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.