Beaconshire Nursing Centre

In the surveyor’s words

From the most serious findings on record at Beaconshire Nursing Centre, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 22, 2025

  This 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. […]

• Immediate jeopardy, isolatedF689Jun 23, 2022

  This citation pertains to MI 509 and MI 557. Based on observation, interview, and record review, the facility failed to provide adequate security and supervision to prevent an elopement from the facility, for one sampled resident (#23) who was moderately cognitively impaired and had diagnoses of paranoid [CONDITION(S)] and diffuse [CONDITION(S)]. Resident #23 (R23) eloped from the facility on 5/16/2022 at 3:06 AM from the front door which was left ajar by a rug. R23 was found approximately 50 minutes later wandering a major street resulting in the likelihood for serious injury, harm, or death. The Immediate Jeopardy (IJ) started on 5/16/2022 and was identified on 6/22/2022. […]

• Actual harm, isolatedF600Jul 24, 2024

  This 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. […]

• Actual harm, isolatedF602May 18, 2023

  This citation pertains to intakes MI00136501 and MI00136279. Based on observation, interview and record review, the facility failed to ensure money was safe from misappropriation for two residents (R201 and R202) of three residents reviewed, resulting in $6,130.00 of unauthorized ATM (Automated Teller Machine) transactions for Resident #201 and theft of $10,200.00 from Resident #202's room (financial loss) and subsequent psychological distress. Findings include: R201 A review of a Facility Reported Incident (FRI) dated 5/1/2023 documented the following: On 4/4/2023 at approximately 9:30 AM, Activity Aide (AA) L accompanied Resident #201 (R201) to the bank to make a withdrawal. The bank teller informed R201 that there was not enough money in the account to make a withdrawal. […]

• Actual harm, isolatedF689Oct 7, 2022

  This citation pertains to MI 177. Based on interview and record review, the facility failed to ensure proper wheelchair transport for one resident (R537) out of two residents reviewed for accidents, resulting in an abrasion, opened wound, hematoma, and an emergency hospital encounter. Findings include: It was reported to the State Agency that during a wheelchair transport a resident fell out of the wheelchair face forward and was then transported to the hospital. On 10/6/2022 at 1:51 PM, Resident #537's (R537) Concerned Family Member (CFM) stated they were present when the resident fell out of the wheelchair. […]