Inspection Reports for
Beaumont Rehabilitation and Healthcare Center
1345 N Madison Ave, Anderson, IN 46011, United States, IN, 46011
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
22.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
431% worse than Indiana average
Indiana average: 4.2 deficiencies/year
Deficiencies per year
40
30
20
10
0
Census
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
Occupancy over time
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Sep 19, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification and licensure survey to assess compliance with regulatory requirements including resident transfer notifications, PASARR screenings, food safety, infection control, and vaccination policies.
Findings
The facility was found deficient in multiple areas including failure to notify the State Ombudsman of resident hospital transfers, failure to provide transfer/discharge notifications and bed hold policies to residents or representatives, untimely PASARR screening completion, unsafe food preparation and sanitation practices, lack of a Quality Assurance and Performance Improvement program for infection control, failure to follow Enhanced Barrier Precautions during wound care, and failure to provide and document COVID-19 and pneumococcal vaccinations per CDC guidance.
Deficiencies (7)
Failed to notify the State Ombudsman of resident transfers to the hospital for 3 of 5 residents and failed to provide transfer/discharge notification and bed hold policy to residents or representatives for 2 of 5 residents reviewed.
Failed to ensure timely completion of a required Level I PASARR assessment for 1 of 2 residents reviewed.
Failed to prepare, serve, and distribute food under safe sanitary conditions regarding food temperatures and sanitation of cookware, potentially impacting all 116 residents.
Failed to develop and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies regarding Enhanced Barrier Precautions.
Failed to ensure Enhanced Barrier Precautions were followed during a dressing change for 1 of 2 residents reviewed for EBP.
Failed to provide pneumococcal vaccination per CDC guidance for 1 of 5 residents reviewed for immunizations.
Failed to provide COVID-19 vaccines per CDC guidance and properly document vaccination status for 1 of 5 residents reviewed.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 116
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 8 | Licensed Practical Nurse | Interviewed regarding transfer/discharge notification and bed hold policy procedures |
| Social Services Assistant | Interviewed about monthly discharge logs and Ombudsman notifications | |
| Social Service Director | SSD | Provided facility policies and interviewed about transfer/discharge notification procedures |
| Social Service Assistant | SSA | Interviewed about PASARR screening process and tracking system issues |
| Dietary Manager | Interviewed regarding food safety and sanitation deficiencies | |
| LPN 15 | Licensed Practical Nurse | Observed and interviewed regarding failure to follow Enhanced Barrier Precautions during dressing change |
| LPN 18 | Licensed Practical Nurse | Interviewed regarding vaccination record oversight and documentation |
| Administrator | Provided facility policies and interviewed about QAPI program and vaccination policies | |
| DON | Director of Nursing | Interviewed regarding infection control expectations and vaccination documentation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 1, 2025
Visit Reason
The inspection was conducted following complaints related to the facility's failure to implement proper interventions for a dependent resident requiring two-person assistance for bed mobility, which resulted in a fall and major head injury.
Complaint Details
The citation relates to complaints 2572704 and 2574936. The investigation found the facility failed to provide two-person assistance as required, leading to the resident falling and sustaining a traumatic brain injury.
Findings
The facility failed to ensure adequate supervision and assistance for a dependent resident, leading to a fall from bed and a traumatic brain injury requiring hospitalization in the ICU. The deficient practice was corrected prior to the survey by staff education and systemic changes.
Deficiencies (1)
Failed to implement interventions of two staff for bed mobility for a dependent resident to prevent a fall from bed, resulting in a major head injury and hospitalization.
Report Facts
Date of incident: Jul 25, 2025
Date of correction: Jul 29, 2025
Heart rate: 102
Blood pressure: 14778
Oxygen saturation: 94
Size of hematoma: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Witnessed the fall and provided care during incident |
| LPN 1 | Licensed Practical Nurse | Responded to fall incident and provided initial care |
| CNA 2 | Certified Nursing Assistant | Provided care for resident earlier on day of incident |
| CNA 5 | Certified Nursing Assistant | Described communication methods for resident care |
| CNA 6 | Certified Nursing Assistant | Described communication methods for resident care |
| LPN 7 | Licensed Practical Nurse | Described communication methods for resident care |
| DON | Director of Nursing | Provided information on assignment sheets and care plans |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 30, 2025
Visit Reason
The document is a paper compliance review related to unrelated findings cited during the investigation of multiple complaints.
Complaint Details
The review pertains to complaints IN00455984, IN00455432, IN00455339, IN00455001, IN00454979, and IN00454955; the facility was found in compliance.
Findings
Beaumont Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of unrelated findings from complaint investigations.
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00455984, IN00455432, IN00455339, IN00455001, IN00454979, and IN00454955) at Beaumont Rehabilitation and Healthcare Center.
Complaint Details
The complaint investigation included six complaint numbers. No deficiencies related to the allegations were cited for any of the complaints. The investigation was conducted by the Indiana State Department of Health on April 1, 2, and 3, 2025.
Findings
No deficiencies related to the complaint allegations were cited. However, unrelated deficiencies were cited regarding failure to provide current education on influenza vaccines and to obtain current influenza vaccination consents for 4 of 6 residents reviewed.
Deficiencies (1)
Facility failed to provide current education on influenza vaccines and to obtain current influenza vaccination consents for 4 of 6 residents reviewed (Residents D, E, G, and H).
Report Facts
Residents reviewed for immunizations: 6
Residents affected by deficient practice: 4
Census: 104
Total capacity: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Pruett | Executive Director | Signed the report and plan of correction. |
| Suzanne Williams | Director of Division LTC | Recipient of the complaint survey report. |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with policies and procedures related to influenza and pneumonia vaccinations, including education and consent documentation for residents.
Findings
The facility failed to provide current education on influenza vaccines and did not obtain current influenza vaccination consents for 4 of 6 residents reviewed. Documentation deficiencies included outdated education materials and missing or incomplete consent forms.
Deficiencies (1)
Failed to provide current education on influenza vaccines and obtain current influenza vaccination consents for 4 of 6 residents reviewed.
Report Facts
Residents reviewed for immunizations: 6
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Clinical Consultant | Interviewed regarding facility vaccination education and consent procedures | |
| Infection Control Provider (ICP) | Interviewed regarding facility vaccination education and consent procedures |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Date: Feb 27, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452484.
Complaint Details
Complaint IN00452484 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00452484 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 110
Census Payor Type Total: 110
SNF/NF Beds: 99
SNF Beds: 11
Medicare Residents: 11
Medicaid Residents: 88
Other Payor Residents: 11
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: Jan 24, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00451854.
Complaint Details
Complaint IN00451854 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. Beaumont Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00451854.
Report Facts
Census Bed Type: 112
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 98
Census Payor Type - Other: 7
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
Date: Nov 22, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00445934 and IN00447536 at Beaumont Rehabilitation and Healthcare Center.
Complaint Details
Investigation of Complaints IN00445934 and IN00447536 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00445934 and IN00447536 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 113
Census Bed Type - SNF: 4
Census Bed Type - Total: 117
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 106
Census Payor Type - Other: 7
Census Payor Type - Total: 117
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
Date: Oct 1, 2024
Visit Reason
This visit was conducted to investigate complaints IN00444442, IN00442644, and IN00441612 at Beaumont Rehabilitation and Healthcare Center.
Complaint Details
Complaints IN00444442, IN00442644, and IN00441612 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00444442, IN00442644, and IN00441612 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 108
Census Bed Type - SNF: 9
Census Total: 117
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 95
Census Payor Type - Other: 14
Inspection Report
Re-Inspection
Census: 109
Capacity: 200
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/15/24 was performed to verify compliance with prior deficiencies.
Findings
At this PSR survey, Beaumont Rehabilitation and Healthcare Center was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.73, and Life Safety Code requirements. The facility was fully sprinklered with a fire alarm system and smoke detection in required areas.
Report Facts
Facility capacity: 200
Census: 109
Inspection Report
Re-Inspection
Census: 119
Deficiencies: 0
Date: Aug 12, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2024-07-02, including a PSR to the Investigation of Complaints IN00436913, IN00436778, and IN00436566.
Complaint Details
Complaints IN00436913, IN00436778, and IN00436566 were investigated and found to be corrected.
Findings
Beaumont Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and the Investigation of Complaints IN00436913, IN00436778, and IN00436566. All complaints were corrected.
Report Facts
Census Bed Type - SNF/NF: 112
Census Bed Type - SNF: 7
Total Census: 119
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 106
Census Payor Type - Other: 9
Total Census Payor: 119
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 0
Date: Aug 6, 2024
Visit Reason
This visit was conducted to investigate complaints IN00439304, IN00439279, IN004399356, and IN00438508 at Beaumont Rehabilitation and Healthcare Center.
Complaint Details
Complaints IN00439304, IN00439279, IN004399356, and IN00438508 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of these complaints.
Report Facts
Census Bed Type - SNF/NF: 118
Census Bed Type - SNF: 9
Census Bed Type - Total: 127
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 111
Census Payor Type - Other: 8
Census Payor Type - Total: 127
Inspection Report
Routine
Census: 122
Capacity: 200
Deficiencies: 7
Date: Jul 15, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with Medicare and Medicaid participation requirements, including emergency preparedness and fire safety.
Findings
The facility was found not in compliance with emergency preparedness testing requirements, fire alarm system maintenance, smoke barrier door functionality, fire drill documentation, smoking regulations, and use of power cords. Specific deficiencies included failure to conduct required emergency plan exercises twice per year, incorrect fire alarm panel date/time, smoke barrier doors not closing properly, missing door closing coordinator on smoke barrier doors, incomplete fire drill transmission verification, cigarette disposal containers mixed with combustible trash, and use of non-approved power strips.
Deficiencies (7)
Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills.
Fire alarm control panel displayed incorrect date and time.
One set of smoke barrier doors did not close completely, leaving a two-inch gap.
One set of corridor doors lacked a door closing coordinator to ensure smoke resistant barrier.
Two of twelve fire drills lacked verification of transmission of fire alarm signal to monitoring station.
Cigarette butt container contained combustible trash mixed with cigarette butts.
Use of power strips in Marketing office and Assistant Director of Nursing's office as substitute for fixed wiring.
Report Facts
Deficiencies cited: 7
Facility capacity: 200
Census: 122
Residents potentially affected: 44
Staff potentially affected: 4
Visitors potentially affected: 2
Residents potentially affected: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Goran Prentoski | Administrator | Signed the inspection report |
| Maintenance Director | Interviewed and involved in findings related to emergency preparedness exercises, fire alarm system, smoke barrier doors, fire drills, smoking area, and power cords | |
| Executive Director | Present at exit conference |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 0
Date: Jul 10, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438396 at Beaumont Rehabilitation and Healthcare Center.
Complaint Details
Complaint IN00438396 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00438396 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 118
Census Bed Type - SNF: 7
Census Total: 125
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 109
Census Payor Type - Other: 12
Inspection Report
Annual Inspection
Census: 125
Capacity: 125
Deficiencies: 12
Date: Jul 2, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of multiple complaints.
Complaint Details
This inspection included investigation of complaints IN00436913, IN00436778, IN00436566, IN00436817, IN00436100, IN00435362, and IN00435861. Deficiencies were cited related to complaints IN00436913, IN00436778, and IN00436566. No deficiencies were cited related to complaints IN00436817, IN00436100, IN00435362, and IN00435861.
Findings
The facility was found deficient in multiple areas including grievance resolution, reporting of alleged abuse, resident safety monitoring, timely completion and submission of assessments, care plan meetings, wound care treatment, respiratory care, medication storage and reconciliation, infection prevention and control, and quality assurance performance improvement activities.
Deficiencies (12)
Failed to resolve and respond to resident grievances in a timely manner for 3 residents related to meal provision and dietary concerns.
Failed to report an allegation of resident abuse to the Indiana State Department of Health for 1 resident.
Failed to investigate, prevent, and correct alleged resident to resident abuse resulting in injury and relocation of a resident.
Failed to complete Quarterly Minimum Data Set (MDS) assessments timely for 4 residents.
Failed to timely submit Minimum Data Set (MDS) discharge assessment for 1 resident.
Failed to schedule, hold, and invite resident representatives to care plan meetings for 3 residents.
Failed to ensure completion of physician ordered wound care treatments for 1 resident.
Failed to provide wound care treatment and care as ordered to promote healing of a pressure injury for 1 resident.
Failed to follow physician orders related to oxygen administration for 2 residents.
Failed to ensure shift to shift narcotic reconciliation was completed for 6 medication carts.
Failed to ensure insulin vials were dated when opened and disposed of when expired for 2 medication carts.
Failed to follow infection prevention and control procedures during wound care related to Enhanced Barrier Precautions for 2 residents.
Report Facts
Deficiencies cited: 11
Residents reviewed for grievance: 3
Residents reviewed for abuse reporting: 4
Residents reviewed for safety monitoring: 1
Residents reviewed for timely MDS: 4
Residents reviewed for MDS submission: 1
Residents reviewed for care plan meetings: 4
Residents reviewed for wound care: 3
Residents reviewed for respiratory care: 4
Medication carts reviewed for narcotic reconciliation: 6
Medication carts reviewed for insulin vial dating: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Goran Pentroski | HFA | Facility representative signing the report. |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the report from Indiana State Department of Health. |
| RN 22 | Named in abuse allegation involving Resident C. | |
| CNA 23 | Reported abuse allegation involving Resident C. | |
| LPN 12 | Observed during wound care without gown use. | |
| CNA 13 | Observed during wound care without gown use. | |
| LPN 33 | Observed expired insulin vials and medication cart narcotic reconciliation. | |
| LPN 9 | Observed undated insulin vials on medication cart. | |
| Family Tree Unit Manager | Provided information about narcotic reconciliation and insulin vial dating. | |
| DON | Director of Nursing | Provided multiple interviews regarding deficiencies and corrective actions. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 2, 2024
Visit Reason
The inspection was conducted due to complaints alleging abuse and failure to report abuse at Beaumont Rehabilitation and Healthcare Center, specifically regarding incidents involving Resident C and Resident E.
Complaint Details
The complaint involved allegations that RN 22 was rough with Resident C, including yelling, grabbing, and forcefully moving the resident, which was reported by CNA 23 but not properly reported to the state by the Administrator. Additionally, complaints involved failure to prevent and monitor resident-to-resident abuse incidents involving Resident E, including physical altercations and inadequate 15-minute checks.
Findings
The facility failed to report an allegation of resident abuse to the Indiana State Department of Health for Resident C and failed to develop and implement a safety plan to prevent resident-to-resident abuse for Resident E, resulting in harm and relocation of Resident E. The facility also failed to properly monitor Resident E on 15-minute checks as required.
Deficiencies (2)
Failed to timely report suspected abuse of Resident C to the Indiana State Department of Health.
Failed to develop and implement a safety plan including 15-minute monitoring checks to prevent resident-to-resident abuse for Resident E.
Report Facts
Residents affected: 4
Residents affected: 1
Dates of incidents: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 22 | Registered Nurse | Named in abuse allegation involving Resident C |
| CNA 23 | Certified Nursing Assistant | Reported abuse allegation against RN 22 involving Resident C |
| Administrator | Did not report abuse allegation to state and made decisions regarding abuse claims | |
| CNA 25 | Certified Nursing Assistant | Indicated Resident E was never monitored on 15-minute checks |
| QMA 26 | Qualified Medication Aide | Indicated Resident E was never monitored on 15-minute checks |
| QMA 29 | Qualified Medication Aide | Reported Resident E wandered and entered other residents' rooms |
| DON | Director of Nursing | Indicated Resident E was not placed on 15-minute monitoring following altercation |
| Corporate Nursing Consultant 7 | Provided facility policy titled Behavior Crisis |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Jul 2, 2024
Visit Reason
The inspection was conducted based on complaints alleging failure to resolve resident grievances timely, failure to report abuse allegations, inadequate safety plans to prevent resident-to-resident abuse, untimely completion and submission of MDS assessments, failure to hold care plan meetings, incomplete wound care treatments, improper oxygen administration, incomplete narcotic reconciliation, improper insulin vial labeling and disposal, and failure to follow infection control procedures.
Complaint Details
The complaint investigation included allegations of failure to resolve resident grievances, failure to report abuse, inadequate safety plans to prevent resident-to-resident abuse, untimely MDS assessments, failure to hold care plan meetings, incomplete wound care, improper oxygen administration, incomplete narcotic reconciliation, improper insulin vial management, and failure to follow infection control procedures.
Findings
The facility was found deficient in multiple areas including failure to resolve resident grievances timely for three residents, failure to report an abuse allegation to the state, failure to implement effective safety plans to prevent resident-to-resident abuse, late completion and submission of MDS assessments, failure to hold care plan meetings for residents, incomplete wound care treatments for two residents, failure to follow physician orders for oxygen administration for two residents, incomplete shift-to-shift narcotic reconciliation on six medication carts, failure to date and dispose expired insulin vials on two medication carts, and failure to follow enhanced barrier precautions during wound care for two residents.
Deficiencies (12)
Failed to resolve and respond to resident grievances in a timely manner for 3 of 3 residents reviewed for choices.
Failed to report an allegation of resident abuse to the Indiana State Department of Health for 1 of 4 residents reviewed for allegations of abuse.
Failed to develop and implement a safety plan (15 minute monitoring checks) to prevent resident to resident abuse resulting in resident being hit, choked, and relocated.
Failed to ensure timely completion of Quarterly Minimum Data Set (MDS) assessments every three months for 4 of 4 residents reviewed.
Failed to ensure timely submission of Minimum Data Set (MDS) assessments for 1 of 1 resident reviewed.
Failed to schedule, hold, and invite resident representatives to care plan meetings for 3 of 4 residents reviewed.
Failed to ensure completion of physician ordered wound care treatments to promote healing of an abrasion for 1 of 2 residents reviewed for skin conditions.
Failed to provide wound care treatment and care as ordered to promote healing of a pressure injury for 1 of 3 residents reviewed for pressure injuries.
Failed to follow physician orders related to oxygen administration for 2 of 4 residents reviewed for respiratory care.
Failed to ensure shift to shift narcotic reconciliation was completed for 6 of 6 medication carts reviewed.
Failed to ensure insulin vials were dated when opened and disposed of when expired for 2 of 6 medication carts reviewed.
Failed to follow infection prevention and control procedures during wound care related to Enhanced Barrier Precautions for 2 of 5 residents reviewed for skin impairments.
Report Facts
Residents reviewed for grievances: 3
Residents reviewed for abuse allegations: 4
Residents reviewed for safety plan: 1
Residents reviewed for timely MDS assessments: 4
Residents reviewed for care plan meetings: 4
Residents reviewed for wound care: 2
Residents reviewed for respiratory care: 2
Medication carts reviewed for narcotic reconciliation: 6
Insulin vials observed expired or undated: 5
Residents reviewed for infection control: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 22 | Registered Nurse | Named in abuse allegation involving Resident C |
| CNA 23 | Certified Nursing Assistant | Reported abuse allegation involving Resident C |
| Dietary Manager | Dietary Manager | Named in resident grievance regarding breakfast service |
| SSD | Social Service Director | Responsible for grievance log and grievance process |
| DON | Director of Nursing | Provided facility policies and interviews regarding deficiencies |
| LPN 12 | Licensed Practical Nurse | Observed not following enhanced barrier precautions during wound care |
| LPN 33 | Licensed Practical Nurse | Observed medication cart narcotic reconciliation and insulin vial issues |
| LPN 9 | Licensed Practical Nurse | Observed medication cart narcotic reconciliation and insulin vial issues |
| Family Tree Unit Manager | Unit Manager | Interviewed regarding oxygen administration and narcotic reconciliation |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS assessment completion and submission |
Inspection Report
Life Safety
Census: 126
Capacity: 200
Deficiencies: 0
Date: Jun 17, 2024
Visit Reason
A Life Safety Code and Pre-Occupancy Survey for bed additions to rooms 117, 119 and 131 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Beaumont Rehabilitation and Healthcare Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with a fire alarm system and smoke detection.
Report Facts
Facility capacity: 200
Census: 126
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 13, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00431082 and IN00431111 completed on April 5, 2024.
Complaint Details
The visit was related to complaint investigations IN00431082 and IN00431111, with compliance found upon paper review.
Findings
Beaumont Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Life Safety
Census: 120
Capacity: 200
Deficiencies: 0
Date: May 3, 2024
Visit Reason
A Life Safety Code and Pre-Occupancy Survey for bed additions to rooms 133, 134 and 135 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Beaumont Rehabilitation and Healthcare Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with a fire alarm system and smoke detection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 5, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to timely report and properly investigate an allegation of misappropriation of property involving a resident's stolen phone.
Complaint Details
This citation relates to Complaints IN00431082 and IN00431111. The facility failed to report the allegation of misappropriation of a resident's phone within the required timeframe and delayed the investigation until police involvement. The investigation was incomplete, lacking staff interviews and surveillance footage.
Findings
The facility failed to report the allegation of misappropriation within the required timeframe and did not thoroughly investigate the incident. The resident's phone was stolen during a hospital transfer, and the facility delayed reporting to the Indiana Department of Health until police involvement. The investigation lacked staff interviews and surveillance footage, and the phone was not returned or replaced.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to thoroughly investigate an allegation of misappropriation of resident property.
Report Facts
Date of resident's hospital transfer: Mar 4, 2024
Date phone was reported lost: Mar 4, 2024
Date phone was reported stolen to authorities: Mar 22, 2024
Date of facility investigation completion: Apr 4, 2024
Date of police report: Apr 5, 2024
Number of resident interviews in investigation: 12
Number of staff interviews provided: 7
CNA 3 shift hours: 14:00-22:00
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Staff member whose residence the stolen phone was tracked to and who was present during the resident's hospital transfer. |
| Administrator | Facility Administrator who was involved in the investigation and communication with the resident's representative. | |
| DON | Director of Nursing | Provided facility policy and indicated she would check into the lack of staff interviews in the investigation. |
Inspection Report
Complaint Investigation
Census: 117
Capacity: 117
Deficiencies: 2
Date: Apr 4, 2024
Visit Reason
This visit was for the investigation of complaints IN00431055, IN00431082, and IN00431111, focusing on allegations of misappropriation of resident property and reporting failures.
Complaint Details
Complaints IN00431082 and IN00431111 were substantiated with federal/state deficiencies cited at F0609 and F0610 related to misappropriation of resident property and failure to report and investigate properly. Complaint IN00431055 had no deficiencies related to the allegations.
Findings
The facility failed to report an allegation of misappropriation of property within the required timeframe and failed to thoroughly investigate the allegation involving Resident C. The resident's phone was stolen during hospital transfer, and the investigation lacked staff interviews and timely reporting. The alleged perpetrator was identified and removed from duty pending investigation.
Deficiencies (2)
Failed to report an allegation of misappropriation of property within required timeframe to the Indiana Department of Health for 1 of 3 residents reviewed (Resident C).
Failed to thoroughly investigate an allegation of misappropriation of resident property for 1 of 3 residents reviewed (Resident C), including lack of staff interviews and incomplete investigation.
Report Facts
Census: 117
Total Capacity: 117
Date of Correction: Apr 23, 2024
Inspection Report
Complaint Investigation
Census: 118
Capacity: 118
Deficiencies: 0
Date: Mar 15, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00429492 and IN00429851 at Beaumont Rehabilitation and Healthcare Center.
Complaint Details
Complaint IN00429492 and Complaint IN00429851 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00429492 and IN00429851 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 118
Census Payor Type: 118
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 0
Date: Feb 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427161.
Complaint Details
Complaint IN00427161 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 123
SNF/NF beds: 7
SNF beds: 116
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 94
Census Payor Type - Other: 22
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 0
Date: Jan 19, 2024
Visit Reason
This visit was for the investigation of complaints IN00425098, IN00425807, IN00426281, and IN00426363, in conjunction with a Post Survey Revisit to the investigation of complaint IN00424249 completed on December 28, 2023.
Complaint Details
Complaints IN00425098, IN00425807, IN00426281, and IN00426363 were not substantiated with any deficiencies. Complaint IN00424249 was corrected.
Findings
No deficiencies related to the allegations were cited for complaints IN00425098, IN00425807, IN00426281, and IN00426363. Complaint IN00424249 was corrected. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 116
Census Bed Type - SNF: 10
Census Bed Type - Total: 126
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 103
Census Payor Type - Other: 13
Inspection Report
Re-Inspection
Census: 126
Capacity: 126
Deficiencies: 0
Date: Jan 19, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00424249 completed on December 28, 2023, conducted in conjunction with investigations of several other complaints.
Complaint Details
Complaint IN00424249 was corrected. Complaints IN00425098, IN00425807, IN00426281, and IN00426363 had no deficiencies related to the allegations.
Findings
Beaumont Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00424249. Complaints IN00425098, IN00425807, IN00426281, and IN00426363 had no deficiencies related to the allegations cited.
Report Facts
Census Bed Type - SNF/NF: 116
Census Bed Type - SNF: 10
Total Census: 126
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 103
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 1
Date: Dec 28, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00422220, IN00423344, and IN00424249. The investigation found no deficiencies related to complaints IN00422220 and IN00423344, but deficiencies related to complaint IN00424249 were cited.
Complaint Details
Complaint IN00424249 was substantiated with federal/state deficiencies cited related to pain management. Complaints IN00422220 and IN00423344 had no deficiencies related to the allegations.
Findings
The facility was cited for a deficiency related to pain management (F697) involving one resident with severe cognitive impairment and a healing dislocated and fractured left shoulder. The facility failed to effectively monitor and treat the resident's pain, resulting in impaired mobility and poor quality of life. The facility disputed the severity level of the citation and requested a reduction from a G to a D level. The plan of correction included staff education, audits, and monitoring to ensure effective pain management.
Deficiencies (1)
Failure to effectively monitor and treat pain for a resident with severe cognitive impairment and a healing dislocated and fractured left shoulder.
Report Facts
Census: 128
SNF/NF Beds: 116
SNF Beds: 12
Medicare Residents: 12
Medicaid Residents: 90
Other Residents: 26
Pain assessments missed: 13
Medication administrations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding resident's pain and pain management issues | |
| QMA 2 | Observed and reported resident's pain and decline | |
| CNA 3 | Reported resident's drastic change and pain |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 28, 2023
Visit Reason
The inspection was conducted due to a complaint (IN00424249) regarding the facility's failure to provide safe and appropriate pain management for a resident with severe cognitive impairment and a healing dislocated and fractured left shoulder.
Complaint Details
This citation relates to complaint IN00424249.
Findings
The facility failed to effectively monitor and treat pain for Resident F, resulting in impaired mobility and poor quality of life. Pain assessments were inconsistently completed, pain medication was not consistently administered, and interventions for pain relief were lacking despite documented high pain levels and observed distress.
Deficiencies (1)
Failure to effectively monitor and treat pain for a resident with severe cognitive impairment and a healing dislocated and fractured left shoulder.
Report Facts
Pain assessment omissions: 8
Pain assessment omissions: 5
Pain ratings: 7
Pain ratings: 5
Pain ratings: 4
Medication administrations: 4
Medication dosage: 650
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 2 | Reported resident's pain to nurses and described resident's decline and pain-related difficulties. | |
| DON | Indicated resident was in pain, noted pain medication was ordered but not consistently given, and described documentation deficiencies. | |
| CNA 3 | Reported resident had a drastic change and was likely experiencing pain. |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 0
Date: Nov 17, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00421706.
Complaint Details
Complaint IN00421706 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 131
Census Bed Type - SNF/NF: 117
Census Bed Type - SNF: 14
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 113
Census Payor Type - Other: 12
Inspection Report
Complaint Investigation
Census: 134
Capacity: 134
Deficiencies: 1
Date: Nov 13, 2023
Visit Reason
This visit was conducted as an investigation of complaints IN00421560 and IN00420764 at Beaumont Rehabilitation and Healthcare Center.
Complaint Details
Complaint IN00421560 had no deficiencies related to the allegations. Complaint IN00420764 was substantiated with federal/state deficiencies cited at F744 related to treatment and services for dementia care.
Findings
The facility failed to document and monitor behaviors and develop and implement a plan of care with targeted behavioral interventions for a cognitively impaired resident (Resident C). Complaint IN00421560 had no deficiencies cited, while complaint IN00420764 resulted in federal/state deficiencies.
Deficiencies (1)
Failed to document and monitor behaviors and develop and implement a plan of care with targeted behavioral interventions for a cognitively impaired resident.
Report Facts
Census: 134
Total Capacity: 134
Medicare Census: 9
Medicaid Census: 114
Other Payor Census: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian McKamie | Executive Director | Signed the report and Plan of Correction |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the report and Plan of Correction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 13, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00420764 completed on November 13, 2023.
Complaint Details
Investigation of Complaint IN00420764; paper compliance review completed with findings of compliance.
Findings
Beaumont Rehabilitation And Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 13, 2023
Visit Reason
The inspection was conducted in response to a complaint regarding the facility's failure to document and monitor behaviors and to develop and implement a care plan with targeted behavioral interventions for a cognitively impaired resident.
Complaint Details
This citation relates to Complaint IN00420764.
Findings
The facility failed to document and monitor the behaviors of a resident with dementia who exhibited aggressive behavior, including biting a staff member. The facility also failed to develop and implement a care plan addressing these behaviors, despite known incidents and policies requiring such documentation and interventions.
Deficiencies (1)
Failed to document and monitor behaviors and develop and implement a plan of care with targeted behavioral interventions for a cognitively impaired resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Reported resident's allegation and noted resident's resistance to care. |
| CNA 1 | Certified Nursing Assistant | Bit by resident during morning care, causing hand to bleed. |
| Memory Care Social Service Director | Social Service Director | Indicated resident's aggressive behaviors and lack of care plan. |
| Director of Nursing | Director of Nursing | Indicated all behaviors should be documented and monitored; facility failed to do so. |
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 0
Date: Oct 23, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420180.
Complaint Details
Complaint IN00420180 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00420180 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 115
Census Bed Type - SNF: 9
Census Total: 124
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 108
Census Payor Type - Other: 7
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 0
Date: Oct 20, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00417057, IN00418023, IN00418619, IN00418658, and IN00419107) at Beaumont Rehabilitation and Healthcare Center.
Complaint Details
Complaints IN00417057, IN00418023, IN00418619, IN00418658, and IN00419107 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 126
SNF/NF beds: 116
SNF beds: 10
Medicare residents: 10
Medicaid residents: 108
Other payor residents: 8
Inspection Report
Census: 121
Deficiencies: 0
Date: Sep 12, 2023
Visit Reason
This visit was for a Quality Assurance Walk Through Survey conducted on September 12, 2023.
Findings
Beaumont Rehabilitation And Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Quality Assurance Walk Through Survey.
Report Facts
Census Bed Type: 121
Census Payor Type: 121
Inspection Report
Complaint Investigation
Census: 123
Capacity: 123
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
This visit was for the investigation of complaints IN00412126, IN00412983, and IN00413830.
Complaint Details
Complaints IN00412126, IN00412983, and IN00413830 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited for any of the complaints investigated. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 123
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 100
Census Payor Type - Other: 12
Inspection Report
Complaint Investigation
Census: 117
Capacity: 117
Deficiencies: 0
Date: Jul 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411451.
Complaint Details
Complaint IN00411451 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00411451 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 10
Medicaid census: 93
Other payor census: 14
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Date: Jun 8, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00409212 and was conducted in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey completed on April 27, 2023.
Complaint Details
Complaint IN00409212 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census: 109
Census Bed Type - SNF/NF: 101
Census Bed Type - SNF: 8
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 93
Census Payor Type - Other: 8
Inspection Report
Re-Inspection
Census: 109
Deficiencies: 0
Date: Jun 8, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on April 27, 2023, and was conducted in conjunction with the Investigation of Complaint IN00409212.
Complaint Details
Investigation of Complaint IN00409212 was conducted in conjunction with this visit.
Findings
Beaumont Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census: 109
Census Bed Type Total: 109
Medicare Census: 8
Medicaid Census: 93
Other Payor Census: 8
Inspection Report
Follow-Up
Census: 111
Capacity: 200
Deficiencies: 0
Date: Jun 1, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 05/09/23 by the Indiana Department of Health.
Findings
At this Post Survey Revisit, Beaumont Rehabilitation and Healthcare Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Routine
Census: 116
Capacity: 200
Deficiencies: 10
Date: May 9, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with federal and state regulations including emergency preparedness, fire safety, and electrical systems.
Findings
The facility was found not in compliance with emergency preparedness training and testing requirements, corridor obstruction by PPE carts without wheels, kitchen fire suppression system inspection, fire alarm system visual inspections, smoke barrier penetrations, GFCI receptacle functionality, electrical receptacle testing in resident rooms, and annual fuel quality testing for the diesel generator.
Deficiencies (10)
Failed to conduct annual training for the Emergency Preparedness Program and demonstrate staff knowledge of emergency procedures.
Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills.
Corridor means of egress were obstructed by PPE carts without wheels, preventing relocation during emergencies.
Failed to ensure semiannual inspection of kitchen fire suppression system; last documented inspection was 02/17/23 with no prior six-month inspection.
Failed to maintain corridor door from kitchen to self-close, compromising smoke compartment integrity.
Failed to perform semiannual visual inspection of fire alarm system components as required by NFPA 72.
Penetrations in smoke barrier walls were not properly sealed to maintain smoke resistance.
Failed to maintain 2 GFCI devices properly for protection against electric shock; devices failed to trip when tested.
Failed to test non-hospital grade electrical receptacles in resident sleeping rooms at least annually.
Failed to perform annual fuel quality test for the facility diesel powered generator.
Report Facts
Facility capacity: 200
Census: 116
Semiannual kitchen fire suppression inspection date: Feb 17, 2023
Date of inspection: May 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian McKamie | Maintenance Supervisor | Interviewed regarding emergency preparedness training and fire alarm system inspections |
Inspection Report
Annual Inspection
Census: 119
Capacity: 119
Deficiencies: 7
Date: Apr 27, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00404475, IN00404749, and IN00406481.
Complaint Details
The survey included investigation of complaints IN00404475, IN00404749, and IN00406481. No deficiencies related to the allegations were cited for any of these complaints.
Findings
The facility was found deficient in multiple areas including failure to provide showers according to resident preferences, failure to maintain a safe, clean, and homelike environment, failure to ensure pressure relieving boots were applied as ordered, insufficient dietary support personnel and sanitation practices, failure to maintain timely communication with hospice providers, and failure to ensure proper infection prevention and control practices during medication administration.
Deficiencies (7)
Failed to provide showers according to resident preferences for 1 of 3 residents reviewed (Resident 26).
Failed to maintain floors in a clean, well-maintained condition, replace transition threshold strips, maintain paint integrity on door frames and handrails, and ensure wallpaper was affixed to the wall for 6 of 6 halls/units observed.
Failed to ensure pressure relieving boots were in place as ordered for 1 of 1 residents reviewed for pressure ulcers (Resident 85).
Failed to ensure dietary staff were competent to perform kitchen essential duties and maintain sanitary conditions, impacting 118 of 119 residents.
Failed to ensure food was prepared, stored, and distributed in a safe and sanitary manner, impacting 118 of 119 residents.
Failed to ensure timely communication between the facility and hospice provider for 1 of 1 residents reviewed for hospice services (Resident 85).
Failed to ensure staff completed hand hygiene during medication administration for 1 of 3 staff observed (QMA 5).
Report Facts
Census SNF/NF: 108
Census SNF: 11
Total Census: 119
Medicare Census: 12
Medicaid Census: 91
Other Payor Census: 16
Dishwasher wash cycle temperature: 108
Dishwasher rinse cycle temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian McKamie | Administrator | Signed report and submitted Plan of Correction |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the report letter |
| QMA 5 | Observed failing to perform hand hygiene during medication administration | |
| LPN 8 | Licensed Practical Nurse | Interviewed regarding shower bed availability and resident bathing preferences |
| LPN 10 | Licensed Practical Nurse | Interviewed regarding shower bed use |
| CNA 9 | Certified Nursing Assistant | Interviewed regarding shower bed use and resident bathing |
| CNA 17 | Certified Nursing Assistant | Interviewed regarding wound care for Resident 85 |
| LPN 18 | Licensed Practical Nurse | Interviewed regarding treatment and orders for Resident 85 |
| Cook 16 | Cook | Interviewed regarding dietary management and kitchen sanitation |
| Cook 15 | Cook | Interviewed regarding kitchen cleaning and expired products |
| Dietary Aide 13 | Dietary Aide | Interviewed regarding dishwasher operation and training |
| Dietary Aide 14 | Dietary Aide | Interviewed regarding dishwasher operation and sanitizer use |
| Maintenance Director | Maintenance Director | Interviewed regarding facility repairs and kitchen sanitation |
| Environmental Services Director | Environmental Services Director | Interviewed regarding facility cleanliness and maintenance |
| Director of Nursing | Director of Nursing | Interviewed regarding resident rights, bathing preferences, and infection control |
Inspection Report
Routine
Deficiencies: 7
Date: Apr 27, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, facility environment, pressure ulcer care, dietary services, hospice services, and infection control.
Findings
The facility was found deficient in multiple areas including failure to honor resident bathing preferences, inadequate maintenance of facility environment, failure to ensure pressure relieving boots were used as ordered, insufficient dietary staff training and unsanitary kitchen conditions, lack of timely communication with hospice providers, and failure to perform proper hand hygiene during medication administration.
Deficiencies (7)
Failed to provide showers according to resident preferences for 1 of 3 residents reviewed (Resident 26).
Failed to maintain floors in a clean, well-maintained condition, replace transition threshold strips, maintain paint integrity on door frames and handrails, and ensure wallpaper was affixed to the wall for 6 of 6 halls/units observed.
Failed to ensure pressure relieving boots were in place as ordered for 1 of 1 residents reviewed for pressure ulcers (Resident 85).
Failed to ensure dietary staff were competent to perform kitchen essential duties, including lack of training on dishwasher temperature and sanitizer monitoring.
Failed to ensure food was prepared, stored, and distributed in a safe and sanitary manner, including dirty kitchen equipment, expired food items, and incomplete dishwasher sanitization.
Failed to ensure timely communication between facility and hospice provider for 1 of 1 residents reviewed for hospice services (Resident 85).
Failed to ensure staff completed hand hygiene during medication administration for 1 of 3 staff observed (QMA 5).
Report Facts
Residents affected: 3
Residents affected: 119
Residents affected: 1
Residents affected: 118
Residents affected: 119
Residents affected: 1
Staff observed: 3
Dishwasher wash cycle temperature: 108
Dishwasher rinse cycle temperature: 120
Dishwasher wash cycle temperature: 112
Dishwasher rinse cycle temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 5 | Observed failing to perform hand hygiene during medication administration | |
| LPN 8 | Licensed Practical Nurse | Interviewed regarding shower bed availability and resident bathing preferences |
| LPN 10 | Licensed Practical Nurse | Interviewed regarding resident bathing preferences and shower bed use |
| CNA 9 | Certified Nursing Assistant | Interviewed regarding shower bed use and resident bathing |
| DON | Director of Nursing | Interviewed regarding resident rights and bathing preferences |
| Environmental Services Director | ESD | Accompanied environmental tour and provided information on facility maintenance |
| Maintenance Assistant | Interviewed regarding transition threshold strips and painting schedule | |
| Dietary Manager | Vacant position; previously managed kitchen | |
| Maintenance Director | Filled in as Dietary Supervisor and provided information on kitchen sanitation | |
| Dietary Aide 13 | Interviewed regarding training and dishwasher monitoring | |
| Dietary Aide 14 | Interviewed regarding training and dishwasher monitoring | |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding hospice communication |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 13, 2023
Visit Reason
The visit was a paper compliance review related to the Investigation of Complaints IN00399161 and IN00400108 completed on March 7, 2023.
Complaint Details
The complaint investigation was related to complaints IN00399161 and IN00400108, and the facility was found to be in compliance.
Findings
Beaumont Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 5
Date: Mar 6, 2023
Visit Reason
This visit was conducted for the investigation of four complaints (IN00399161, IN00399658, IN00400108, and IN00402205) regarding facility conditions and care.
Complaint Details
Complaint IN00399161 and IN00400108 were substantiated with federal/state deficiencies cited. Complaints IN00399658 and IN00402205 had no deficiencies related to the allegations.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, including issues with rusted kitchen door frames, unsecured personal refrigerator in a resident room, peeling wallpaper, and unsafe food storage practices such as dented cans and pest presence in the kitchen.
Deficiencies (5)
Failed to maintain kitchen door frames in a safe manner, including rust and loosened frames.
Failed to secure a personal refrigerator placed on a dresser in a resident room, posing safety risks.
Failed to maintain wall coverings in resident rooms in good repair, with peeling wallpaper observed.
Failed to ensure canned foods were stored safely; dented cans were found in the dry food storage area.
Failed to maintain a sanitary environment for plating resident servings; presence of gnats near uncovered trash receptacle in kitchen.
Report Facts
Census: 120
Total Capacity: 120
Dented cans: 3
Survey dates: March 6 and 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian McKamie | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Administrator | Interviewed regarding rusted door frames and facility conditions | |
| Dietary Manager | Interviewed regarding dented cans and pest control in kitchen |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Mar 6, 2023
Visit Reason
The inspection was conducted based on complaints related to facility maintenance and food safety issues, including concerns about kitchen door frames, personal refrigerator safety, wall coverings, and food storage and sanitation practices.
Complaint Details
This Federal tag relates to complaints IN00400108 and IN00399161.
Findings
The facility failed to maintain kitchen door frames safely, secure a personal refrigerator in a resident room, and maintain wall coverings in good repair. Additionally, the facility failed to ensure canned foods were stored safely and maintain a sanitary environment for plating resident servings, with observations of dented cans and pest presence in the kitchen.
Deficiencies (5)
Failed to maintain kitchen door frames in a safe manner, including rust and loosened frames.
Failed to secure a personal refrigerator placed on a five drawer dresser in a resident room.
Failed to maintain wall coverings in resident rooms in good repair, with peeling wallpaper observed.
Failed to ensure canned foods were stored safely, with dented cans observed in the dry food storage area.
Failed to maintain a sanitary environment for plating resident servings, with gnats swarming over an uncovered trash receptacle.
Report Facts
Weight of dented can: 6.75
Weight of dented can: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding rusted door frames, personal refrigerator, and peeling wallpaper | |
| Dietary Manager | Interviewed regarding dented cans and pest control in the kitchen |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 10, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00399012 completed on January 18, 2023.
Complaint Details
Investigation of Complaint IN00399012 completed on January 18, 2023; facility found in compliance.
Findings
Beaumont Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 110
Capacity: 110
Deficiencies: 2
Date: Jan 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399012, which was substantiated with federal/state deficiencies cited related to the allegations.
Complaint Details
Complaint IN00399012 was substantiated. The facility failed to report injuries from a fall for Resident C and failed to provide appropriate treatment for pressure ulcers for Resident B.
Findings
The facility failed to report injuries from a fall requiring hospital intervention for one resident and failed to implement interventions for a resident with suspected deep tissue injuries. Deficiencies related to reporting alleged violations and treatment of pressure ulcers were cited.
Deficiencies (2)
Failure to report injuries from a fall that required hospital intervention for one resident.
Failure to implement interventions for a resident with two suspected deep tissue injuries.
Report Facts
Census: 110
Total Capacity: 110
Medicare Census: 18
Medicaid Census: 80
Other Payor Census: 12
Deficiency Completion Date: Jan 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian McKamie | HFA | Facility representative who signed the report and submitted the Plan of Correction |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the complaint survey report from the Indiana State Department of Health |
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: Jan 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00398761.
Complaint Details
Complaint IN00398761 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint IN00398761 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 112
Census Bed Type Total: 112
Census Payor Type Total: 112
Medicare Census: 15
Medicaid Census: 87
Other Payor Census: 10
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Date: Dec 22, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00397243.
Complaint Details
Complaint IN00397243 - Substantiated. No deficiencies related to the allegations were cited.
Findings
Complaint IN00397243 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 114
Census Payor Type Total: 114
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 21, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00395685 completed on December 8, 2022.
Complaint Details
Complaint IN00395685 was investigated and found to be in compliance as of December 21, 2022.
Findings
Beaumont Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 109
Capacity: 109
Deficiencies: 1
Date: Dec 7, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00395685 and IN00393526 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00395685 was substantiated with related federal/state deficiencies cited at F607. Complaint IN00393526 was substantiated but no deficiencies related to the allegations were cited.
Findings
The facility was found to have substantiated deficiencies related to complaint IN00395685 involving failure to ensure staff immediately reported suspected verbal abuse and/or mistreatment of residents to the Administrator. Complaint IN00393526 was substantiated but no deficiencies were cited related to that allegation.
Deficiencies (1)
Failed to ensure staff immediately reported suspected verbal abuse and/or mistreatment of residents to the Administrator.
Report Facts
Census Bed Type - SNF/NF: 99
Census Bed Type - SNF: 10
Total Census: 109
Census Payor Type - Medicare: 18
Census Payor Type - Medicaid: 81
Census Payor Type - Other: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian McKamie | HFA | Signed the Plan of Correction and correspondence |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the survey report and Plan of Correction |
| CNA 2 | Certified Nursing Aide | Witnessed verbal abuse and failed to immediately report it |
| RN 1 | Registered Nurse | Alleged to have been verbally abusive to residents |
| Administrator | Received abuse report from CNA 2 on 11/28/2022 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
Paper compliance review to unrelated findings cited during a Complaint Survey completed on August 17, 2022.
Findings
Beaumont Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the unrelated findings.
Inspection Report
Complaint Investigation
Census: 113
Capacity: 113
Deficiencies: 1
Date: Aug 17, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00387808, IN00387721, IN00387327, and IN00387338 at Beaumont Rehabilitation and Healthcare Center.
Complaint Details
Complaint IN00387808 - Substantiated with no deficiencies related to allegations cited. Complaint IN00387721 - Substantiated with no deficiencies related to allegations cited. Complaint IN00387327 - Unsubstantiated due to lack of evidence. Complaint IN00387338 - Substantiated with no deficiencies related to allegations cited.
Findings
The complaint survey found three complaints substantiated with no deficiencies related to the allegations cited, and one complaint unsubstantiated due to lack of evidence. Unrelated deficiencies were cited, including a medication storage violation where a medication overflow cart was found unlocked and unattended.
Deficiencies (1)
Facility failed to ensure medications were stored securely; a medication overflow cart was observed unlocked and unattended near the nurses station.
Report Facts
Census: 113
Total Capacity: 113
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Buroker | Director of Division Long Term Care | Recipient of the report letter |
| Timothy J Cooper | Temporary Permit | Submitted the Plan of Correction letter |
| Director of Nursing | Informed about the unlocked medication cart and involved in corrective actions | |
| LPN 9 | Licensed Practical Nurse | Interviewed regarding medication cart storage |
| Infection Control Preventionist | Interviewed regarding medication cart storage |
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