Inspection Reports for
Beauvais Rehab and Healthcare Center

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.

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.

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.

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.

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.

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.

The facility was found to be in noncompliance with several Life Safety Code requirements including means of egress, discharge from exits, vertical openings enclosure, hazardous areas enclosure, HVAC smoke dampers, smoking regulations, and electrical systems maintenance and testing. Multiple deficiencies were identified that could potentially affect residents.

The facility failed to provide adequate quality of care and pain management for residents, including failure to promote physical well-being, assess and manage pain, and implement physician orders. Deficiencies were noted in nursing care, pain assessment, and skin condition monitoring.

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.

The facility was found not in substantial compliance with Life Safety Code requirements, including blocked exit passageways, fire doors failing to latch, fire alarm system testing deficiencies, and oxygen storage noncompliance. Multiple deficiencies were identified related to means of egress, horizontal exits, fire alarm system maintenance, and gas equipment storage.

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.

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.

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.

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.

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.

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.

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.

The facility failed to provide a functioning resident call light system with working audio and visual components for all residents on the 100 South hall. Several residents experienced non-functioning call lights, and no alternative communication devices were provided, posing a risk to resident safety.

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.

The facility was found deficient in multiple areas including resident rights, reasonable accommodations, professional standards of care, nutrition and hydration, and staffing requirements. Specific issues included failure to respect resident dignity, inadequate assistance with meals, medication administration errors, and lack of a full-time Director of Nursing.

The facility failed to obtain written authorization for withdrawals from resident trust accounts and failed to properly manage resident funds, including incorrect withdrawals and misappropriation by a former Business Office Manager. Several residents' financial records showed unauthorized or unverified transactions.

The complaint investigation was triggered by allegations of abuse involving Resident #8. The allegations included a resident being hit by a staff member and failure of staff to report the abuse to DHSS. The investigation found that staff and administration did not report the allegations timely or properly, and the abuse was ultimately unsubstantiated.

The facility failed to follow their policy and state and federal regulations by not immediately reporting an allegation of employee to resident abuse to the Department of Health and Senior Services (DHSS). The investigation found inconsistent and unsubstantiated allegations, but the facility did not ensure timely reporting and investigation of the abuse allegations.

The facility failed to ensure that dependent residents received showers as scheduled and were well-groomed, clean, and free of odors. Multiple residents were found to have unmet ADL needs, including refusal of showers and inadequate care documentation.

The complaint involved failure to notify the resident's representative after a fall requiring EMS and allegations of abuse by a staff member. The investigation found no substantiated abuse but confirmed failures in notification and reporting procedures.

The facility failed to notify the resident's representative after a fall requiring emergency medical services and did not follow proper abuse reporting procedures. The grievance policy was not properly implemented, and the facility failed to ensure timely reporting of alleged abuse.

The facility failed to ensure appropriate care and services for residents with pressure ulcers, including failure to notify physicians of x-ray results, incomplete weekly skin assessments, and inadequate wound documentation. The wound care team and nursing staff did not consistently follow policies for skin assessments and treatment documentation.

The complaint investigation was substantiated with findings of inadequate care, failure to prevent falls and pressure ulcers, insufficient staff supervision, and failure to notify physicians of significant changes in resident condition.

The facility was found to be out of compliance with multiple regulatory requirements including failure to notify physicians timely, inadequate documentation of resident care and medication administration, insufficient staff training, and failure to prevent pressure ulcers and falls. The facility also failed to maintain adequate supervision and care plans for residents at risk of elopement and wandering.

The facility was found to have multiple deficiencies related to resident care, including failure to provide reasonable accommodations, inadequate staff training, incomplete assessments, and insufficient wound care and infection control practices.

The facility failed to maintain the fire alarm system with required semi-annual inspections, maintain electrical wiring in compliance with NFPA 70, conduct required fire drills quarterly on each shift, properly dispose of cigarette butts and ensure smoking regulations, and secure oxygen cylinders according to NFPA code. These deficiencies had the potential to affect all occupants of the facility.

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.

The complaint investigation substantiated violations related to resident dignity/privacy, medication safety, and pest control issues.

The facility failed to ensure residents' rights to dignity and privacy, left medications unsecured on a medication cart, and did not maintain an effective pest control program, resulting in rodent and insect infestations.

The facility failed to provide adequate care to sampled residents, resulting in a deficiency related to quality of care. Issues included failure to prevent urinary tract infections and aspiration risks, inadequate monitoring and documentation, and failure to follow physician orders.

The facility was found to have multiple deficiencies including failure to properly administer medications, inadequate abuse prevention policies, incomplete resident care plans, and insufficient staff training. Several regulatory requirements were not met as evidenced by observations, interviews, and record reviews.

The facility failed to maintain exit pathways, kitchen range hood inspections, portable fire extinguisher signage and maintenance, and proper oxygen cylinder storage according to NFPA standards. These deficiencies affected all residents, staff, and occupants in the event of a fire.

The facility failed to follow the resident's plan of care and use mechanical lifts properly, resulting in a resident suffering fractures after a fall. The facility also failed to follow policies regarding gait belt use during transfers, leading to injuries for multiple residents.