Inspection Reports for
Beauvais Rehab and Healthcare Center
3625 MAGNOLIA AVE, SAINT LOUIS, MO, 63110-4048
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
19.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
251% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
137 residents
Based on a September 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 137
Deficiencies: 1
Date: Sep 26, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's funds by a Certified Nurse Aide (CNA A) who used the resident's debit card beyond the authorized purpose of purchasing snacks.
Complaint Details
The complaint investigation was substantiated. The resident's bank notified the facility of suspicious charges on 9/8/25. The facility reimbursed the resident and terminated the CNA involved. Police and Department of Health and Senior Services were notified. The resident was alert and oriented and received psychosocial follow-up.
Findings
The facility failed to protect one resident from misappropriation of property when CNA A used the resident's debit card to transfer money to themselves via Cash App over a two-month period, withdrawing a total of $483.40 and reimbursing only $29.40. The facility reimbursed the resident the full amount after the issue was discovered, suspended and terminated the employee, and provided staff in-service training on resident rights and misappropriation of funds.
Deficiencies (1)
Failed to protect resident from misappropriation of property by CNA A who used resident's debit card for unauthorized Cash App transfers.
Report Facts
Census: 137
Amount misappropriated: 483.4
Amount reimbursed: 483
Number of residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Employee who misappropriated resident funds and was terminated |
| Administrator | Facility Administrator who was notified of suspicious charges, contacted police, suspended and terminated CNA A, and reimbursed the resident | |
| Director of Nursing | Director of Nursing (DON) | Provided information about CNA A's prior settlement agreement and facility in-service training |
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 4
Date: Jun 6, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to an altercation between residents involving physical abuse and threats with a weapon, as well as concerns about medication management and behavioral health care.
Complaint Details
The complaint investigation was triggered by an incident where Resident #3 physically assaulted Resident #2, threatened him with a knife, and caused injury. The facility was found to have inadequate supervision and response to the incident. Additional complaints involved medication management failures and behavioral health care deficiencies.
Findings
The facility failed to protect a resident from physical abuse by a roommate who threatened him with a knife. Staff were found to be inadequately supervising residents on one-to-one observation. The facility also failed to follow up on medication orders after finding filled prescription bottles in a resident's room. Additionally, the facility did not provide an adequate behavioral management program for a resident with escalating aggressive behaviors and substance abuse issues.
Deficiencies (4)
Failed to protect a resident from physical abuse and threats by a roommate with a knife.
Failed to follow up with physicians to obtain medication orders after finding filled prescription bottles in a resident's room.
Failed to provide appropriate supervision during one-to-one observation, allowing residents to have a physical altercation.
Failed to provide a behavioral management program for a resident with frequent verbal and physical aggression and substance abuse.
Report Facts
Residents affected: 7
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Provided testimony about one-to-one observation and incident details |
| ADON F | Assistant Director of Nursing | Interviewed regarding medication order follow-up and supervision policies |
| DON | Director of Nursing | Interviewed about nursing staff expectations and behavioral health care |
| Administrator | Provided information about resident behaviors, incident response, and facility policies | |
| CNA C | Certified Nursing Assistant | Witnessed resident altercation and provided written statement |
| LPN G | Licensed Practical Nurse | Interviewed about medication order processing and follow-up |
| CMT E | Certified Medication Technician | Interviewed about medication administration and awareness of orders |
| Social Worker | Provided information about resident's substance abuse and behavioral issues | |
| ADON A | Assistant Director of Nursing | Interviewed about resident admission and behavioral interventions |
Inspection Report
Routine
Census: 136
Deficiencies: 19
Date: Mar 21, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey of Beauvais Rehab and Healthcare Center to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including privacy breaches with medical records, inadequate cleaning of shower rooms, failure to complete significant change assessments, inaccurate Minimum Data Set (MDS) assessments, failure to update PASARR level one screenings, lack of hospice care plans, failure to follow physician orders for helmet use, failure to assist residents in accessing vision services, inadequate supervision and staffing, lack of medication administration competencies for Certified Medication Technicians (CMTs), insufficient registered nurse coverage, failure to monitor psychotropic medication target behaviors, improper medication labeling and storage, poor food palatability, failure to properly explain binding arbitration agreements, and lapses in infection control practices.
Deficiencies (19)
Failed to ensure medical records containing personal health information were not accessible to unauthorized residents or visitors.
Failed to ensure the fifth-floor shower room was cleaned as required.
Failed to complete a significant change Minimum Data Set (MDS) within required timeframes for one resident.
Failed to ensure Minimum Data Set (MDS) assessments were completed accurately for two residents.
Failed to update Pre-admission Screening and Resident Review (PASARR) level one with new diagnosis for one resident.
Failed to develop and implement a care plan for hospice services for one resident.
Failed to ensure staff followed physician orders for helmet use for one resident.
Failed to ensure vision services related to cataract surgery were provided and rescheduled as needed for one resident.
Failed to ensure one resident did not smoke inside the facility and lacked adequate supervision while smoking.
Failed to ensure oxygen was administered per physician's order for one resident.
Failed to ensure adequate staffing on the fifth floor, with multiple nights having only one staff member on duty.
Failed to ensure medication administration competencies were completed for Certified Medication Technicians (CMTs).
Failed to ensure eight hours of Registered Nurse (RN) coverage every day.
Failed to monitor target behaviors for psychotropic medication use for one resident.
Failed to ensure medications were labeled with open and discard dates, individual insulin syringes labeled with resident's name, and expired medications disposed of for multiple medication carts.
Failed to ensure food prepared was palatable for seven residents.
Failed to ensure binding arbitration agreements were explained and understood by residents or representatives for three residents.
Failed to implement infection prevention and control program including hand hygiene and prevention of cross-contamination during medication administration and meal delivery.
Failed to offer pneumococcal vaccines for two residents who consented to vaccination.
Report Facts
Residents affected: 27
Facility census: 136
Weight loss percentage: 11.28
Staffing shifts with one staff member: 18
Medication carts reviewed: 4
Residents reviewed for palatability: 7
Residents reviewed for binding arbitration: 3
Residents reviewed for pneumonia vaccination: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT6 | Certified Medication Technician | Left EMR screens open exposing confidential medical information |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including EMR privacy, helmet use, hospice care plan, oxygen administration, staffing, medication competencies, and vaccination |
| MDS Coordinator | MDS Coordinator (MDSC) | Interviewed regarding MDS assessments, PASARR updates, and hospice care plan |
| CNA2 | Certified Nurse Aide | Observed resident smoking in locked bathroom and unable to find helmet |
| LPN8 | Licensed Practical Nurse | Interviewed regarding helmet use documentation and oxygen administration |
| Scheduler | Staff Scheduler | Interviewed regarding staffing shortages and call-offs |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding medication labeling, infection control, and staff competencies |
| CMT2 | Certified Medication Technician | Observed administering inhaler without gloves and poor hand hygiene |
| Administrator | Facility Administrator | Interviewed regarding binding arbitration agreements and infection control |
| Regional Director of Business Development | Regional Director of Business Development (RDBD) | Interviewed regarding binding arbitration agreements |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding food complaints and seasoning requests |
Inspection Report
Routine
Census: 136
Deficiencies: 3
Date: Mar 21, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulations related to resident safety, staffing adequacy, and nursing coverage at Beauvais Rehab and Healthcare Center.
Findings
The facility failed to maintain a clean shower environment on the fifth floor, ensure adequate nursing staff coverage on the fifth floor, and provide the required eight hours of registered nurse coverage daily. These deficiencies had the potential to affect resident health, safety, and quality of care.
Deficiencies (3)
Failure to ensure the fifth-floor shower room was cleaned as required, with orange-colored stains observed and no documentation of cleaning.
Failure to provide adequate nursing staff on the fifth floor for four of 18 residents reviewed, including long call light response times and insufficient staff coverage on night shifts.
Failure to ensure eight hours of Registered Nurse coverage every day for all 136 residents, with multiple days lacking RN coverage.
Report Facts
Residents affected: 1
Residents affected: 4
Facility census: 136
Days without RN coverage: 19
Nights with only one staff member on fifth floor: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician 1 | Certified Medication Technician | Observed talking on phone during shift and delayed call light response |
| Housekeeping Manager | Housekeeping Manager | Confirmed shower cleaning was supposed to be daily and acknowledged lack of documentation |
| Scheduler | Scheduler | Provided information on staffing shortages and call-offs affecting coverage |
| Interim Director of Nursing | Interim Director of Nursing | Confirmed lack of RN coverage and staffing concerns |
Inspection Report
Routine
Census: 137
Deficiencies: 2
Date: Feb 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including pain management, skin integrity, and adherence to physician orders for residents with complex medical needs.
Findings
The facility failed to provide appropriate treatment and care according to physician orders and resident preferences for multiple residents, including inadequate pain management, failure to prevent skin breakdown, and insufficient interventions for residents with contractures and mobility limitations. Staff did not consistently implement orders to get residents out of bed for meals or perform necessary hygiene care, and there were issues with missed medical appointments due to transportation problems.
Deficiencies (2)
Failure to provide services to promote the highest practicable physical well-being for residents with pain and mobility issues, including inconsistent repositioning and transfers.
Failure to adequately address breakthrough pain and carry out physician's orders for neurological assessments and Botox treatments.
Report Facts
Census: 137
Pain level ratings: 8
Pain level ratings: 5
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician B | Physician | Issued orders for pain management and neurological consults; involved in resident care decisions |
| Nurse C | Nurse | Reported on resident care practices and challenges with repositioning and hygiene |
| Certified Nurse Aide A | CNA | Provided observations on resident pain and care difficulties |
| Assistant Director of Rehab | Assistant Director of Rehabilitation | Provided information on therapy interventions and resident positioning |
| Director of Nurses | DON | Discussed issues with missed appointments and expectations for nursing care |
| Administrator | Facility Administrator | Outlined facility policies and expectations regarding transportation and nursing standards |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Nov 9, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident care, activities, pain management, and medical record maintenance.
Findings
The facility was found deficient in multiple areas including failure to notify the physician about a resident's significant skin condition change, failure to provide meaningful activities for residents on the secured dementia unit, failure to assess and treat a resident's rash appropriately, failure to provide pain medication as ordered for a resident, and failure to maintain complete and accessible hospital discharge documentation for a resident.
Deficiencies (5)
Failure to notify the physician when there was a need to alter treatment for a resident's skin condition.
Failure to consistently provide a program of meaningful activities in accordance with the resident's needs, interests, and preferences.
Failure to ensure a resident's rash was assessed and treated appropriately.
Failure to ensure a resident received pain medication as ordered by the physician.
Failure to maintain complete and readily accessible medical records, including hospital discharge documentation.
Report Facts
Residents reviewed for skin concerns: 3
Residents reviewed for activities: 3
Residents reviewed for pain management: 3
Residents reviewed for hospitalizations: 2
Resident #100 admission date: Mar 23, 2023
Resident #43 admission date: May 20, 2022
Resident #538 admission date: Oct 2, 2023
Resident #70 admission date: Sep 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #10 | Licensed Practical Nurse | Completed admission assessment and documented pain level for Resident #538. |
| ADON #11 | Assistant Director of Nursing | Involved in pain medication access and hospital discharge documentation. |
| CNA #35 | Certified Nurse Aide | Observed and reported skin condition of Resident #100. |
| CNA #36 | Certified Nurse Aide | Reported lack of activities on secured dementia unit. |
| CNA #40 | Certified Nurse Aide | Filed grievance about lack of activities on secured dementia unit. |
| AA #47 | Activity Assistant | Responsible for activities on secured dementia unit. |
| LPN #43 | Licensed Practical Nurse | Reported on skin assessments for Resident #100. |
| LPN #44 | Licensed Practical Nurse | Managed Resident #70's care during hospitalization and return. |
| DON | Director of Nursing | Oversaw nursing care and activity program. |
| ADON/IP | Assistant Director of Nursing/Infection Preventionist | Conducted skin assessments and interviewed regarding Resident #100. |
| Administrator | Facility Administrator | Responsible for overall facility operations and activities. |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding hospital discharge documentation for Resident #70. |
| HRD | Human Resources Director | Provided staff scheduling information. |
| Director of Clinical and Reimbursement Services | Director of Clinical and Reimbursement Services | Provided hospital documentation for Resident #70. |
Inspection Report
Routine
Deficiencies: 14
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, medication management, activities, food safety, pest control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity with urinary catheter privacy covers, incomplete care planning participation, failure to notify physicians of skin condition changes, incomplete care plans for dementia, inadequate grooming and hygiene assistance, lack of meaningful activities on the secured dementia unit, failure to assess and treat a resident's rash, failure to administer pain medication timely, failure to post nurse staffing information visibly, improper food storage and sanitation, unclean dumpster area, incomplete hospital discharge documentation, improper PPE use for COVID-19 positive resident, and ineffective pest control program with mice sightings.
Deficiencies (14)
Failed to conceal the urine collection bag for a resident's indwelling urinary catheter to maintain dignity.
Failed to invite the resident or responsible party to participate in the care planning process.
Failed to notify the physician when there was a need to alter treatment for a resident's skin concerns.
Failed to ensure resident care plans were comprehensive, specifically lacking dementia care interventions.
Failed to provide services necessary to maintain good grooming and personal hygiene.
Failed to consistently provide a program of meaningful activities in accordance with the resident's needs and preferences.
Failed to ensure a rash was assessed and treated appropriately for a resident.
Failed to ensure a resident received pain medication as ordered by the physician in a timely manner.
Failed to post nurse staffing information in an area highly visible to residents and visitors within two hours of shift start.
Failed to ensure food storage and preparation items were maintained in a clean and sanitary condition.
Failed to keep the area surrounding dumpsters free of debris.
Failed to maintain complete and readily accessible medical records for a resident hospitalized and returned to the facility.
Failed to ensure staff wore appropriate personal protective equipment (PPE) when caring for a COVID-19 positive resident.
Failed to maintain an effective pest control program as evidenced by mice sightings on multiple units.
Report Facts
Residents affected by catheter privacy deficiency: 1
Residents affected by care planning participation deficiency: 1
Residents affected by skin notification deficiency: 1
Residents affected by incomplete care plan: 1
Residents affected by grooming and hygiene deficiency: 1
Residents affected by lack of meaningful activities: 1
Residents affected by rash treatment deficiency: 1
Residents affected by pain medication deficiency: 1
Days nurse staffing information not posted: 3
Opened salad dressing containers not dated: 4
Mouse sightings: 3
Rodent/insect glueboards placed: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #7 | CNA | Acknowledged catheter drainage bag was without privacy cover |
| Certified Nursing Assistant #8 | CNA | Stated catheter drainage bag should always be covered |
| Assistant Director of Nursing #9 | ADON | Stated nurses and CNAs responsible for catheter bag privacy covers |
| Director of Nursing | DON | Stated nursing staff responsible for catheter bag privacy covers and care plan meetings |
| Administrator | Stated staff responsible for catheter bag privacy covers and expected care plan meetings | |
| Licensed Practical Nurse #6 | LPN | Discussed care plan initiation and dementia care |
| Certified Nurse Aide #35 | CNA | Observed resident rash and discussed skin care |
| Primary Care Physician | PCP | Stated no calls received about resident rash |
| Assistant Director of Nursing/Infection Preventionist | ADON/IP | Observed resident rash and discussed skin assessment |
| Licensed Practical Nurse #10 | LPN | Completed admission assessment and documented pain |
| Assistant Director of Nursing #11 | ADON | Discussed emergency medication kit and pain medication |
| Licensed Practical Nurse #44 | LPN | Notified doctor of high blood sugar and called ambulance |
| Nursing Assistant #53 | NA | Delivered meal to COVID-19 positive resident without full PPE |
| Nursing Assistant #54 | NA | Entered COVID-19 positive resident room without full PPE |
| Dietary Manager | DM | Discussed kitchen sanitation and food safety |
| Dietary Aide | DA | Responsible for cleaning kitchen equipment |
| Maintenance Director | Discussed pest control and dumpster area | |
| Pest Control Specialist | PCS | Discussed pest control program and mice sightings |
| Regional Nurse Consultant | Discussed hospital discharge documentation and pharmacy recommendations | |
| Attending Physician #9 | Discussed pharmacy recommendations for antipsychotic medication |
Inspection Report
Annual Inspection
Census: 133
Deficiencies: 2
Date: Sep 19, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards related to wound care, pressure ulcer prevention and treatment, and foot care for residents.
Findings
The facility failed to ensure proper pressure ulcer care and prevention, including timely assessment, documentation, physician notification, and treatment initiation for residents with pressure injuries. Additionally, the facility failed to provide appropriate foot care, resulting in extremely dry and flaky skin for sampled residents.
Deficiencies (2)
Failure to provide appropriate pressure ulcer care including identification, documentation, monitoring, physician notification, and treatment initiation for residents with pressure injuries.
Failure to provide appropriate foot care resulting in extremely dry, flaky, and peeling skin on residents' feet.
Report Facts
Census: 133
Pressure ulcer size: 4.6
Pressure ulcer size: 4.8
Pressure ulcer depth: 2
Pressure ulcer size: 9.5
Pressure ulcer size: 7
Pressure ulcer depth: 2
Pressure ulcer size: 3
Pressure ulcer size: 2
Pressure ulcer depth: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON E | Assistant Director of Nurses | Notified about pressure ulcer and involved in wound care and resident family notification |
| Nurse R | Night shift nurse who assessed pressure ulcer and called physician for treatment order | |
| Nurse T | Evening shift nurse who reported pressure ulcer and coordinated treatment orders | |
| Nurse Q | Day shift nurse who described wound care procedures and physician order process | |
| Nurse P | Nurse who documented skin assessments and physician communications regarding pressure injury | |
| CNA W | Certified Nurse Aide | Reported pressure ulcer discovery and assisted with skin assessment |
| CNA F | Certified Nurse Aide | Reported pressure ulcer observation and applied lotion to resident's dry skin |
| DON | Director of Nurses | Oversight of wound care and treatment order processes |
| Regional Nurse Consultant | Explained transcription error causing treatment order omission |
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 3
Date: Jul 18, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, as well as concerns about foot care and resident safety related to elopement.
Complaint Details
The complaint investigation focused on allegations that the facility failed to provide adequate pressure ulcer care, proper foot care, and failed to prevent elopement of a resident with dementia. The resident eloped twice in July 2023, once found at a grocery store 3.2 miles away and transported to the hospital, and again left the facility without staff knowledge. The facility failed to notify family or document the elopements properly.
Findings
The facility failed to ensure proper pressure ulcer care for residents with actual pressure injuries, including inadequate documentation, delayed treatment orders, and failure to notify family and wound care specialists. Additionally, the facility failed to provide appropriate foot care for residents with extremely dry, flaky skin. The facility also failed to provide adequate supervision and protective oversight for a resident at high risk of elopement, resulting in the resident leaving the facility twice without staff knowledge.
Deficiencies (3)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including inadequate documentation and delayed treatment.
Failure to provide appropriate foot care, resulting in extremely dry, flaky skin for residents.
Failure to provide adequate supervision to prevent elopement of a resident at high risk, resulting in two elopements.
Report Facts
Census: 133
Resident elopement distance: 3.2
Pressure ulcer size: 9.5
Pressure ulcer size: 8.9
Pressure ulcer size: 2
Pressure ulcer size: 4.6
Pressure ulcer size: 4.8
Pressure ulcer size: 2
Pressure ulcer size: 3
Pressure ulcer size: 2
Pressure ulcer size: 0.2
Wandering risk score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nurse Aide | Reported door locking issues and resident elopement details |
| ADON E | Assistant Director of Nurses | Notified about pressure ulcer treatment order issues and resident elopement; provided interviews on care expectations |
| CNA G | Certified Nurse Aide | Worked night shift when resident eloped; provided statement about resident behavior and door issues |
| CNA I | Certified Nurse Aide | Reported resident missing on 7/9/23 and door issues |
| Maintenance Assistant | Reported door repairs and confirmed door alarm functionality | |
| Maintenance Director | Verified door functionality after elopement | |
| DPOA A | Durable Power of Attorney for resident; reported resident found at grocery store after elopement | |
| DPOA B | Durable Power of Attorney for resident; picked up resident from hospital and returned to facility | |
| CNA W | Certified Nurse Aide | Assisted with skin assessment and ointment application |
| CNA F | Certified Nurse Aide | Provided care and lotion application for resident with dry skin |
| Nurse R | Nurse | Provided interview regarding pressure ulcer assessments and reporting |
| Nurse T | Nurse | Assessed pressure ulcer and called physician for treatment order |
| Nurse Q | Nurse | Described wound care procedures and communication with wound nurse |
| CMT L | Certified Medication Technician | Administered medications post-elopement and reported door issues |
| Administrator | Interviewed regarding policies and elopement incident | |
| DON | Director of Nursing | Interviewed regarding treatment order issues and elopement incident |
| Regional Nurse Consultant | Explained transcription error causing missing treatment order |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 2
Date: May 11, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the failure of the facility to provide a functioning call light system with working audio and visual components to residents on the 100 South hall.
Complaint Details
The complaint investigation was triggered by reports that call lights on the 100 South hall had been non-functioning since 5/6/23, resulting in residents being unable to alert staff for assistance. Residents reported delays in care and lack of alternative communication devices. Maintenance was unaware of the issue until 5/11/23 when repairs began.
Findings
The facility failed to provide a working call light system to all 25 residents on the 100 South hall, did not provide alternative or assistive devices when the call light system was not working, and residents reported delays in receiving assistance. Maintenance was unaware of the issue until the day of the survey and repairs were initiated that day.
Deficiencies (2)
Failure to provide a functioning call light system with working audio and visual components to all residents on the 100 South hall.
Failure to provide alternative or assistive devices to dependent residents when the call light system was not working.
Report Facts
Residents affected: 25
Census: 141
Dates call lights non-functioning: 5
Delay in assistance: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Unaware of call light outage until 5/11/23; replaced blown transformer causing outage | |
| Administrator | Reported intermittent call light issues but was unaware of full outage until 5/11/23; expected staff to report and increase rounding |
Inspection Report
Annual Inspection
Census: 138
Deficiencies: 6
Date: Apr 28, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations regarding resident rights, care, nutrition, staffing, and other regulatory requirements at Beauvais Rehab and Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to respect resident dignity, inadequate assistance with activities of daily living, failure to follow physician orders for medication administration, inadequate personal hygiene care, failure to support nutritional status including weight monitoring and dietary interventions, and lack of a full-time Director of Nursing. Deficiencies were generally cited at minimal or actual harm levels affecting a few to some residents.
Deficiencies (6)
Failure to ensure staff respected the personal dignity of a resident by leaving the resident exposed and clipping nails during meal service.
Failure to reasonably accommodate resident needs by not setting up meals for a resident requiring assistance.
Failure to follow physician orders for administering IV antibiotics and changing PICC line dressing.
Failure to provide necessary personal hygiene care resulting in residents being left soiled for extended periods.
Failure to adequately support nutritional status of residents including failure to notify physician of weight loss, failure to reweigh residents as required, failure to implement dietary recommendations, and failure to provide meals and supplements as ordered.
Failure to hire, maintain or designate a full-time Director of Nursing despite census over 60 residents.
Report Facts
Sample size: 14
Census: 138
Weight loss: 25.7
Weight loss: 6.5
Weight loss: 5.6
Missed antibiotic doses: 7
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PT D | Physical Therapist | Named in finding for clipping resident's nails during meal service |
| CNA N | Certified Nursing Assistant | Named in finding for failure to assist resident with meal set up |
| Nurse B | Interviewed regarding medication administration and resident care deficiencies | |
| RD K | Registered Dietician | Provided dietary recommendations and interviewed regarding nutritional deficiencies |
| NP G | Nurse Practitioner | Medical Director's NP interviewed regarding resident care and weight loss |
| CNA E | Certified Nursing Assistant | Interviewed regarding resident care and nutritional concerns |
| CMT C | Certified Medication Technician | Interviewed regarding nutritional supplement administration |
Inspection Report
Annual Inspection
Census: 143
Deficiencies: 16
Date: Mar 16, 2020
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility was cited for multiple deficiencies including failure to provide reasonable accommodations for residents, incomplete employee background checks, inaccurate resident assessments, incomplete care plans, inadequate discharge planning, failure to provide adequate assistance with activities of daily living, improper wound care and infection control practices, failure to monitor nutritional status, unsafe medication storage, inadequate food service practices, incomplete medical records, insufficient staff training, and lack of effective quality assurance processes.
Deficiencies (16)
Failed to provide reasonable accommodations for resident bed/side rails affecting independence and safety.
Failed to complete timely and complete background checks for employees including nurse aide registry checks.
Failed to ensure resident Minimum Data Set (MDS) assessments accurately reflected resident status for multiple residents.
Failed to develop and implement baseline care plans for newly admitted residents within 48 hours.
Failed to develop and implement comprehensive person-centered care plans addressing infections, nutrition/weight loss, and pain management for multiple residents.
Failed to plan resident discharge to meet goals and needs including caregiver support and referrals.
Failed to provide care and assistance for activities of daily living including grooming and hygiene per resident wishes and standards of practice.
Failed to provide appropriate treatment and care according to orders, resident preferences and goals, including wound care and pain management.
Failed to provide safe, appropriate dialysis care/services including routine assessment and monitoring of dialysis access sites.
Failed to ensure nurses and nurse aides have appropriate competencies and training to provide nursing and related services, including wound care.
Failed to ensure nurse aides received at least 12 hours of in-service education annually based on performance review.
Failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards.
Failed to ensure food was served at safe and appetizing temperatures and was palatable.
Failed to procure food from approved sources and maintain sanitary conditions in food storage and preparation areas.
Failed to maintain complete and accurate medical records for residents.
Failed to provide staff education on dementia care, abuse, neglect, exploitation, and reporting, especially for agency staff.
Report Facts
Resident census: 143
Deficiency citations: 16
Weight loss percentage: 10.11
Weight loss percentage: 12.21
Weight loss percentage: 12.82
Training hours: 0
Training hours: 7
Training hours: 6.5
Training hours: 0
Training hours: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Named in wound care treatment observation and deficiencies |
| Nurse Q | Wound Nurse | Named in wound care treatment observation and deficiencies |
| Nurse O | Wound Nurse | Named in wound care treatment observation and deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding wound care, training, and deficiencies |
| Administrator | Administrator | Interviewed regarding wound care, training, and deficiencies |
| Quality Assurance Nurse | QA Nurse | Interviewed regarding training and quality assurance |
| Dietary Manager | Dietary Manager | Interviewed regarding food service deficiencies |
| Human Resource Director | Human Resource Director | Interviewed regarding employee background checks and PPD documentation |
| Registered Nurse C | Registered Nurse | Named in employee background check deficiency |
| Dietary Aid I | Dietary Aid | Named in employee background check deficiency |
| Licensed Practical Nurse L | Licensed Practical Nurse | Named in employee background check deficiency |
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