Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beaumont Health Care Center during CMS and state inspections, most recent first.
Failure to Assess and Document Indwelling Catheter Findings: Two residents with indwelling catheters had sediment observed in catheter tubing, but staff did not document catheter assessments, notify the MD, or record related treatment in the progress notes. Both residents had bladder dysfunction and significant dependence on staff, and facility staff acknowledged that sediment should have been assessed and reported per catheter care orders and policy.
Medication error rate exceeded the allowed threshold after surveyors found 2 errors in 31 opportunities. An LPN gave a resident only half of an ordered calcium dose during med pass, and an RN administered sliding-scale Humalog from an insulin pen labeled with a past use-by date. The record review and observations showed the staff did not follow the ordered dose and did not verify the insulin pen labeling before administration.
Medication Left Unattended on Top of Cart: An LVN left a Lidocaine Patch 4% on top of a locked med cart and walked away to the nurse station to get scissors, leaving the medication out of view while a resident in a wheelchair was nearby and other staff passed by. The LVN stated she should not have left the patch unattended, and the ADON, DON, and Administrator stated meds must remain secure and under direct observation or locked in the cart.
Failure to Use Gowns During Bed Bath Under EBP: A resident with pressure ulcers and severely impaired cognition was on enhanced barrier precautions for wounds, with bathing listed as a high-contact activity requiring gown and glove use. During a bed bath, two CNAs did not wear gowns, and their arms and clothing touched the resident and linens. The CNAs said they did not think the resident required enhanced barrier precautions, while the ADON/ICP and DON stated gowns and gloves were expected for this care.
Surveyors found that two residents' beds on one hall were not maintained in safe operating condition, with one newly admitted resident lying in a bed missing both the footboard and attachment brackets, and another resident at moderate fall risk assigned to a bed missing the footboard and having metal brackets protruding beyond the mattress. Staff acknowledged that a replacement footboard was available in storage but not installed, and that the missing footboards had not been reported through the facility's electronic system, despite a policy requiring regular bed frame inspections and adherence to manufacturers' maintenance recommendations.
A resident with dysphagia, aphasia, prior stroke, and a PEG tube, who was NPO and dependent on tube feeding, had physician orders and MAR entries for TwoCal 2.0 at 80 ml/hr with a 45 ml free water flush every hour. During observation, the feeding pump was correctly set to 80 ml/hr for formula, but the water flush was programmed to deliver 45 ml every two hours while the feeding was running. An LVN confirmed the discrepancy between the pump settings and the physician’s orders, and the DON stated that nurses were responsible for ensuring pump parameters matched orders. Facility policy required feeding tubes to be managed according to physician orders, including flush frequency and volume, but no recent related staff training was provided when requested by surveyors.
Several residents requiring oxygen therapy did not have physician orders or care plans for their oxygen use, and one resident received oxygen at a higher rate than ordered. Additionally, a resident's oxygen concentrator filter was found to be visibly dirty on multiple occasions, despite facility policy and staff training requiring regular cleaning. Nursing and administrative staff confirmed these deficiencies in respiratory care practices.
Dietary staff, including the DM, were observed with unrestrained hair while preparing and serving food, in violation of facility policy and FDA Food Code. Staff only secured their hair after surveyor intervention, and the DM acknowledged responsibility for ensuring compliance with hair restraint requirements.
Two residents with respiratory conditions were receiving oxygen therapy without corresponding care plans or physician orders. Staff and the DON confirmed the absence of care plans addressing oxygen therapy, despite facility policy requiring comprehensive, individualized care plans based on resident assessments.
The facility failed to ensure each resident's drug regimen was free from unnecessary drugs for three residents. One resident was taking Ozempic for weight loss without an appropriate diagnosis, another was prescribed valproic acid for dementia, and a third had incorrect indications for Eliquis and pramipexole dihydrochloride. The DON and former DON confirmed that medications should have appropriate diagnoses for their use.
The facility failed to ensure that a resident was not given psychotropic drugs without an appropriate diagnosis. The resident, with diagnoses of senile degeneration of the brain and dementia, was prescribed Trazadone and Zoloft for dementia, which is not an appropriate indication. The DON confirmed this, and the facility could not provide a relevant medication policy when requested.
The facility failed to ensure a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for a resident with chronic conditions, as the document lacked necessary physician information. Interviews confirmed the DNR was invalid, risking unwanted lifesaving procedures.
A facility failed to ensure proper care for a resident receiving enteral feeding. An LVN did not verify the G-tube placement by checking for residuals before administering water and medications, relying instead on auscultation, which is no longer recommended. The resident had severe cognitive impairment and required all nutrition and hydration via G-tube due to dysphagia and aphasia. The facility's outdated policy and lack of awareness among staff contributed to this deficiency.
Failure to Assess and Document Indwelling Catheter Findings
Penalty
Summary
The facility failed to ensure appropriate catheter care and monitoring for two residents with indwelling urinary catheters. Resident #16 had diagnoses including neuromuscular dysfunction of the bladder, aphagia following a stroke, and a sacral pressure ulcer. Her MDS showed she was dependent on staff for toileting, bed mobility, and bathing, and that she had an indwelling catheter. Her care plan and orders directed staff to provide catheter care each shift, monitor for abnormalities such as sediment or obstruction, and notify the physician of unusual urine findings. However, the record contained no progress notes documenting assessment of the catheter, sediment, physician notification, or other related treatment during the reviewed period. During observation, Resident #16’s catheter tubing contained a large amount of sediment. The catheter bag was hanging below the bladder with a privacy cover in place. The LVN who was interviewed stated that sediment in an indwelling catheter should prompt notification of the doctor, assessment of output, and possible catheter change if ordered, and she acknowledged that such findings should be documented in progress notes. The ADON/Infection Preventionist also stated that nurses should look for signs of infection, that sediment and physician notification should be documented, and that she would need to contact the doctor for a urinalysis after observing the sediment. Resident #5 also had diagnoses including neuromuscular dysfunction of the bladder and aphagia following a stroke, and her MDS showed severe cognitive impairment, dependence on staff for toileting, bed mobility, and bathing, and an indwelling catheter. Her care plan and orders required catheter care each shift, monitoring for abnormal urine findings, and notification of the physician for signs of infection or unusual urine appearance. The record contained no progress notes documenting catheter assessment, sediment, physician notification, or other related treatment. During observation, her catheter tubing contained thick white sediment, which increased on a later observation. An LVN stated she had not assessed the catheter and would notify the physician to ensure the resident did not have a UTI, and the DON and ADON stated they had not been made aware of the catheter condition and expected staff to assess and report thick white sediment.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent. Surveyors calculated a medication error rate of 6.45%, based on 2 errors out of 31 opportunities, involving 2 residents and 2 staff members during medication pass observations and record review. For one resident, the record showed an order for Calcium 600 mg to be given as 1200 mg by mouth each morning. During a medication pass observation, an LVN administered only one 600 mg tablet from facility stock instead of the ordered 1200 mg dose. During interview, the LVN acknowledged that she should have given 2 tablets totaling 1200 mg and that only one tablet had been administered. For another resident, the record showed an order for Humalog insulin on a sliding scale. During an observed medication pass, an RN checked the resident’s blood sugar at 229 mg/dL and administered 4 units of Humalog from an insulin pen that had an orange label indicating a use-by date of 06/29/2026. The RN stated she used the pen with the added orange label and said the date on the label was the opened date but was on the wrong label, while denying that she had opened or labeled the pen. The DON and ADON later stated that staff had placed the opened date on the wrong label and that the pen was being replaced with a corrected one.
Medication Left Unattended on Top of Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and kept under proper security when a topical pain patch was left on top of a medication cart and out of the nurse’s visual sight. During an observation, an LVN pulled the medication cart to a resident’s doorway, locked the cart and the electronic medical record, and then walked approximately 40 feet away to the nurse station to get scissors, leaving the Lidocaine Patch 4% on top of the cart unattended. A resident in a wheelchair was self-propelling nearby while multiple staff members walked past the cart and attended to another resident. During interview, the LVN stated she should not have left the topical pain patch unattended on the cart and said she should have taken it with her or placed it back inside the cart while getting scissors. She stated the medication was not in her view when she left and acknowledged that someone could have taken it and it could have caused them to become sick. The ADON, DON, and Administrator each stated that medications should remain secure, that nurses must maintain a view of the medication cart, and that medications should not be left unattended on top of the cart. The facility policy stated that all drugs and biologicals must be stored in locked compartments and that during a medication pass, medications must be under direct observation or locked in the medication storage area/cart.
Failure to Use Gowns During Bed Bath Under Enhanced Barrier Precautions
Penalty
Summary
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 reviewed for infection control. Resident #68 was admitted with diagnoses including pressure ulcers and had physician orders and a care plan indicating enhanced barrier precautions due to wounds, with interventions required during high-contact care such as dressing, bathing, transferring, hygiene, linen changes, brief changes, toileting assistance, device care, and wound care. Her admission MDS indicated severely impaired cognition, four unstageable pressure ulcers, and dependence on 1-2 staff for bathing and grooming. During an observation, CNA D and CNA E were bed bathing Resident #68 without wearing gowns, and their arms and clothing touched the resident and her linens while turning and repositioning her. During interview, both CNAs said they did not think Resident #68 required enhanced barrier precautions. The enhanced barrier sign was posted on the room wall and PPE was hanging on the closet door. The ADON/ICP and DON stated the CNAs should have worn gowns and gloves during the bed bath, and the DON stated her expectation was that staff wear gowns and gloves when performing bed baths for residents on enhanced barrier precautions. The facility’s policy stated gowns and gloves are required for high-contact care activities, including bathing, for residents on enhanced barrier precautions.
Failure to Maintain Beds With Proper Footboards and Safe Hardware
Penalty
Summary
The facility failed to maintain resident beds in safe operating condition by not ensuring that two beds on Hall 100 had footboards properly installed. For one resident, a female with high blood pressure and Alzheimer's disease who was newly admitted to room [ROOM NUMBER] A, surveyors first observed the bed unoccupied and missing both the footboard and the brackets needed to attach it, with visible holes in the frame where brackets should be mounted. Later the same day, the resident was observed in this same bed, which remained without a footboard, although it was in the lowest position. For another resident, a female with heart disease, muscle weakness, a history of falls, and a documented moderate fall risk, surveyors observed her bed in room [ROOM NUMBER] A to be missing the footboard but equipped with metal brackets that extended approximately two to three inches beyond the mattress. The resident, who had no impaired cognition and a BIMS score of 13, reported she had not hurt herself on the metal and had not reported the issue. Staff interviews revealed that a Laundry/Housekeeping Supervisor had seen a new footboard in storage but was unaware it was needed, and the Maintenance Supervisor stated that no one had reported the missing footboards in the electronic reporting system. The facility had a written policy requiring regular inspections of all bed frames and for the Maintenance Director to follow manufacturers' recommendations and establish a maintenance and inspection schedule.
Failure to Follow Enteral Feeding Flush Orders for PEG Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for enteral feeding flushes for a resident with a PEG tube. The resident was an older female with dysphagia, aphasia, a history of cerebral infarction, and a history of aspiration, who was NPO and dependent on tube feeding and water flushes for nutrition and hydration. Her quarterly MDS showed she received more than half of her total calories via PEG tube. The active physician order and MAR specified TwoCal 2.0 at 80 ml/hr for 20 hours with a free water flush (FWF) of 45 ml every hour while the feeding was running. During observation of the tube feeding pump, the formula rate was correctly set at 80 ml/hr, but the water flush was programmed to deliver 45 ml every two hours instead of every hour as ordered, while the feeding was connected and running. An LVN confirmed that the order was for 80 ml/hr with a 45 ml water flush every hour and acknowledged that the pump was set to flush every two hours. The LVN stated that night nurses hung the feeding and day nurses restarted it. The DON stated that nurses were expected to ensure the feeding rate and flushes matched the physician’s orders and that they should check pump parameters accordingly. The facility’s policy on care and treatment of feeding tubes required that feeding tubes be utilized according to physician orders, including the frequency and volume of flushes, and that the RD be used to estimate nutritional and hydration needs. The surveyors requested recent training related to this area, and none were provided before exit.
Failure to Ensure Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to several residents requiring oxygen therapy, as evidenced by multiple deficiencies in physician orders, care planning, and equipment maintenance. Two residents with diagnoses including chronic respiratory failure, COPD, and acute respiratory distress were observed receiving continuous oxygen therapy without corresponding physician orders or care plans addressing their oxygen use. Nursing staff confirmed the absence of orders and care plans, and acknowledged that these residents were on oxygen for shortness of breath, but had not obtained the necessary documentation. Another resident, who had a physician order and care plan for oxygen at 3 liters per minute (LPM), was observed receiving oxygen at a higher rate of 5 LPM. Nursing staff and the wound nurse verified the incorrect setting, and the nurse adjusted the concentrator to the ordered rate after the discrepancy was identified. The DON and Administrator both stated that nurses are expected to follow physician orders for oxygen therapy and to check settings regularly. A fourth resident, with severe cognitive impairment and a history of respiratory failure and COPD, was observed with a visibly dirty oxygen concentrator filter on multiple occasions. Nursing and administrative staff acknowledged that the filter should have been cleaned when the oxygen tubing was changed, and that both maintenance and nursing staff share responsibility for ensuring filters are clean. Facility policy and in-service records indicated that filters should be cleaned according to manufacturer recommendations and when visibly soiled, but this was not done in this instance.
Failure to Ensure Proper Hair Restraints During Food Preparation and Service
Penalty
Summary
The facility failed to ensure that all dietary staff properly restrained their hair while preparing and serving food in the kitchen. During observations, the Dietary Manager (DM) was seen with unrestrained hair on both sides of her neck, approximately 3 to 4 inches long, while operating the dish machine and walking by food preparation areas. Later, during lunch service, the DM continued to have unrestrained hair while placing soup in bowls. Another kitchen staff member was observed plating food with a section of unrestrained hair on top of her head and a long braid not contained within her hair net. Both staff members only secured their hair and washed their hands after being prompted by the surveyor. Interviews confirmed that the DM was responsible for ensuring staff compliance with hair restraint policies and acknowledged that unsecured hair could fall into food. The facility's policy and the FDA Food Code require food employees to wear effective hair restraints to prevent contamination. The Administrator stated that her expectation was for all kitchen staff to wear hair nets while serving food or working in the kitchen.
Failure to Develop and Implement Oxygen Therapy Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing oxygen therapy for two residents with significant respiratory diagnoses. Both residents had documented needs for oxygen therapy, as evidenced by their medical diagnoses, MDS assessments, and nursing progress notes indicating use of oxygen for conditions such as chronic respiratory failure, COPD, and hypoxia. Despite these needs, neither resident had a care plan that included oxygen therapy, and there were no physician orders for oxygen administration in their records. Observations confirmed that both residents were receiving oxygen at specified flow rates, and staff interviews verified the absence of corresponding care plans and physician orders. The Director of Nursing (DON) acknowledged that oxygen therapy should have been included in the care plans and confirmed the omission after reviewing the records. The DON also stated that responsibility for completing care plans was shared among all administrative nurses of the interdisciplinary team, but could not explain why the care plans for oxygen therapy were missing. Facility policy requires that comprehensive care plans be developed for each resident, including measurable objectives and timeframes to meet all identified needs from the resident's assessment.
Failure to Ensure Drug Regimen Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure each resident's drug regimen was free from unnecessary drugs for three residents reviewed. Resident #9, a female with type 2 diabetes and morbid obesity, was taking Ozempic for weight loss without an appropriate diagnosis for its use. The Director of Nursing (DON) and former DON/Corporate Nurse confirmed that medications should have a diagnosis for their indication, and Resident #9 was taking Ozempic for weight loss rather than for diabetes management. Resident #47, a female with senile degeneration of the brain and dementia, was prescribed valproic acid for dementia, which the DON confirmed was not an appropriate indication for the medication. Resident #104, a female with paroxysmal atrial fibrillation and restless leg syndrome, had orders for Eliquis and pramipexole dihydrochloride with incorrect indications listed in the physician orders. The resident confirmed she did not have Parkinson's disease, despite the medication being indicated for antiparkinson's use. During interviews, the DON and former DON/Corporate Nurse reiterated that medications should have appropriate diagnoses for their use. The surveyor requested a medication policy related to medications and diagnoses, but the facility did not provide one. This lack of appropriate indications for medications could place residents at risk of complications related to receiving unnecessary medications.
Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were not given psychotropic drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, for one resident, the facility did not have an appropriate diagnosis or adequate indication for the use of Trazadone and Zoloft, both antidepressants. The resident, an elderly female with diagnoses of senile degeneration of the brain and dementia, had physician orders for these medications to treat dementia, which is not an appropriate indication. During an interview, the Director of Nursing confirmed that dementia was not an appropriate indication for these medications. Additionally, the facility was unable to provide a medication policy related to medications and diagnoses when requested by the surveyor.
Failure to Ensure Valid DNR for Resident
Penalty
Summary
The facility failed to ensure the right to formulate an advance directive was provided for a resident. Specifically, the facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for a resident who had an order for DNR. The resident, an elderly female with chronic obstructive pulmonary disease, hypertension, and an abdominal aortic aneurysm, was alert and expressed that she did not want CPR performed. However, the OOH-DNR in her electronic medical record was incomplete, lacking the printed name and license number of the physician, rendering it invalid. Interviews with the Director of Nursing (DON), the former DON/Corporate Nurse, and the Social Worker (SW) confirmed that the DNR was invalid due to missing physician information. The DON acknowledged that incomplete DNRs could lead to lifesaving procedures being performed against the resident's wishes. The facility's policy required that DNR orders be completed and signed by the attending physician and the resident, which was not adhered to in this case.
Failure to Verify G-Tube Placement Properly
Penalty
Summary
The facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complications. Specifically, LVN A did not verify the placement of a resident's G-tube by checking for residual before administering water and medications. This oversight was observed during a medication administration session, where LVN A only used auscultation to check the tube placement, which is no longer recommended according to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities. LVN A admitted to forgetting to check for residuals and acknowledged the potential negative outcomes of this failure, such as administering medications to a stomach that was too full. The resident in question had severe cognitive impairment, was dependent on all ADLs, and received nutrition and hydration exclusively via G-tube due to dysphagia and aphasia. The care plan for this resident included verifying tube placement prior to use, which was not followed in this instance. The Director of Nursing (DON) and the Corporate Nurse were both interviewed and revealed gaps in their awareness and adherence to current guidelines for verifying G-tube placement. The DON was unaware that auscultation was no longer recommended, and the facility's policy, last revised in March 2015, still included auscultation as a method for verifying tube placement. The Corporate Nurse mentioned that the corporation was in the process of reviewing and updating facility policies, including the Confirming Placement of Feeding Tube policy. Despite training provided to LVNs during orientation, this incident highlighted a lapse in following the correct procedures for G-tube placement verification, potentially compromising resident safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Beaumont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spindletop Hill Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 15 | 0 |
| Avir At Beaumont | 0.9 mi | ★★★★★ | 4 | 0 |
| Beaumont Nursing And Rehabilitation | 1 mi | ★★★★★ | 16 | 1 |
| College Street Health Care Center | 1 mi | ★★★★★ | 0 | 0 |
| Calder Woods | 1.2 mi | ★★★★★ | 6 | 0 |
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