Beaufont Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Beaufont Health and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF695Oct 3, 2024

  Based on Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide respiratory care and services to maintain the highest practicable wellbeing for one resident, (Resident #1) in a survey sample of 2 residents resulting in harm for Resident #1. The findings included: For Resident #1, the facility staff failed to assess and monitor the Resident's respiratory status and intervene with appropriate measures prior to the death of the Resident who was suffering labored breathing & respiratory difficulty. No other tracheostomy Residents were residing in the facility at the time of survey so could not be added to the sample. Resident #1 was a discharged Resident so a closed record review was conducted. […]

• No harm, potential for more than minimal, patternF658May 14, 2024

  Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to maintain the professional standards of medication administration in nursing practice for two Residents (Resident # 6 and #37) in a survey sample of 50 Residents. The findings included: For Resident # 6, the facility staff failed to administer medications and treatments on several dates as ordered by the physician Resident # 6 was admitted to the facility in April 2024 with diagnoses that included but were not limited to: Dementia, contractures and sepsis. Resident #6's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 04/12/2024 was a quarterly assessment. […]

• No harm, potential for more than minimal, patternF658May 24, 2022

  Based on staff interview, facility documentation review, and clinical record review and in the course of a complaint investigation, the facility staff failed to provide multiple care and services in accordance with professional standards and according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: 1a. For Resident #259 the facility staff failed to provide medications timely. On 5/22/22 and 5/23/22, a closed clinical record review was conducted. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/23/22, the facility staff provided Surveyor F with a listing of medication administration times for several specific days. […]

• No harm, potential for more than minimal, patternF760May 24, 2022

  Based on Observation, Staff interview, clinical record review, and facility document review, the facility failed to prevent significant medication errors regarding 4 medications for two Residents, (Resident #29 & #259) in a sample of 46 residents. The findings included; 1. For Resident #29, the Resident was given two doses of an anticoagulant significant drug, instead of the single dose ordered by the physician. Resident #29 was admitted to the facility on [DATE]. The Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On Monday 5-23-22 at 8:00 a.m., during the Medication administration pour and pass observations with LPN (G), Resident #29's medications were observed while being prepared for administration, and was observed receiving those medications. […]

• No harm, potential for more than minimal, patternF886May 24, 2022

  Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with the Centers for Disease Control and Prevention (CDC) guidance for 5 Residents, Residents #106, #69, #62, #104, and #310, in a sample of 8 Residents reviewed for new admission COVID-19 testing. The findings included: For Residents #106, #69, #62, #104, and #310, the facility staff failed to conduct COVID-19 testing upon their admission to the facility. […]