Beaumont Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 1, 2025

  Based on record review and interview, the facility failed to implement interventions of two staff for bed mobility for a dependent resident (Resident B) to prevent a fall from bed when the resident rolled from the bed during care and struck their head on a nightstand, resulting in a major head injury and hospitalization in the Intensive Care Unit (ICU). (Resident B) This deficient practice was corrected on 7/29/25, prior to the start of the survey, and was therefore past noncompliance. Findings include:Resident B's clinical record was reviewed on 7/30/2025 at 10:00 a.m. […]

• Immediate jeopardy, isolatedF686Sep 24, 2021

  Based on record review and interview, the facility failed to prevent the development of pressure injuries for a resident identified at risk. This deficient practice led to the resident developing an infection in an unstageable, necrotic wound, leading to septic shock for 1 of 4 residents reviewed for wounds (Resident F). The immediate jeopardy began on [DATE], when Resident F was found to have developed a necrotic pressure injury. The Administrator, DON, Executive Director, and Director of Clinical Services were notified of the immediate jeopardy on [DATE] at 2:18 p.m. The immediate jeopardy was removed on [DATE], but non-compliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. […]

• Actual harm, isolatedF697Dec 28, 2023

  Based on observation, interview, and record review, the facility failed to effectively monitor and treat pain for a resident with severe cognitive impairment with a healing dislocated and fractured left shoulder for 1 of 1 resident reviewed for pain. (Resident F) This resulted in Resident F having impaired mobility and poor quality of life as evidenced by not leaving his bed per his usual routine. Finding includes: During an observation on 12/27/23 at 12:59 p.m., Resident F was lying in bed with the head of the bed elevated, positioned on his back, unclothed. His eyes were open and he was picking at his incontinent brief with his right hand. […]

• Actual harm, isolatedF684Mar 22, 2022

  Based on record review and interview, the facility failed to transfer a resident to the hospital for care following resident representative's request and physical decline resulting in resident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident B) This deficient practice resulted in Resident B being hospitalized for [CONDITION(S)] (blood poisoning). The facility also failed to provide care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident D) Findings include: 1. During a phone interview on 3/15/22 at 1:19 p.m., the resident's family member indicated the resident was admitted to the facility following a hospitalization after a stroke and COVID-19 infection. He had a catheter and in the past was susceptible to urinary tract infections in the past. […]

• Actual harm, isolatedF690Mar 22, 2022

  Based on observation, interview and record review, the facility failed to ensure proper indwelling urinary catheter care was provided on each shift, to prevent infection in a resident dependent for activities of daily living, for 1 of 3 residents reviewed for urinary tract infections. (Resident C) This deficiency resulted in a hospitalization of Resident C for a urinary tract infection with [CONDITION(S)]. Findings include: During an interview at the time of observation on 3/14/22 at 3:51 p.m., Resident C indicated he was dependent on staff to provide catheter care and other activities of daily living due to his immobility. He indicated he required a continuous urinary catheter and staff typically cleaned his catheter insertion site a couple of times each week. […]