Beaconshire Nursing Centre
Inspection Findings
F-Tag F0880
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficient practice pertains to 1232811.Based on observation, interview, and record review the facility failed to don appropriate personal protective equipment (PPE) for one resident (Resident R407) of three resident reviewed for enhanced-barrier precautions resulting in the potential for the transmission of infectious organisms.Findings include:On 9/16/2025 at 10:50 AM, Licensed Practical Nurse (LPN) A was observed to perform wound care and peri care on Resident R407. LPN A was assisted by Certified Nurse Assistant (CNA) B. LPN A and CNA B did not put on a gown during patient care despite there being an Enhanced Barrier Precaution (EBP) sign on
the door indicating Resident R407 was on (EBP).During this time LPN C (unit manage) enter Resident R407 room while wound care was being performed.On 9/16/2025 at 11:15 AM, CNA B was interviewed about (EBP) and said a gown should be worn when a resident has a foley catheter, wound and doing personal care.On 9/16/2025 at 11:17 AM, LPN A was interviewed and queried about the care they had performed on Resident R407.
LPN A said she should have worn a gown because Resident R407 had an open wound and a foley catheter.On 9/16/2025 at 11:49, AM LPN C was interviewed and acknowledged when they entered the room during patient care they did not see LPN A nor CNA B wearing a gown. LPN C said they should have been wearing a gown because Resident R407 was on EBP.On 9/16/2025 at 1:00 PM, the Director of Nursing (DON) was interviewed and said they had the signs posted on door Resident R407. The DON also acknowledged there were orders in Resident R407 chart indicating they were on EBP, but staff did not follow the orders or signs. The DON said
they would expect staff to follow the orders.Record review revealed Resident R407 was initially admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident R407 had the following diagnosis: urinary tract infection, osteomyelitis (bone infection), pressure ulcer stage IV, unspecified injury at C4 and neurogenic bowel.Review of Minimum Data Set (MDS) for Resident R407 from the Quarterly Review dated 7/19/2025 noted Resident R407 Brief Interview for Mental Status was a 15 out of 15 indicating Resident R407 was cognitively intact.Review of facility policy titled, Enhanced Barrier Precautions with a review date of 9/16/2025 noted, It is the policy of this facility to implement enhanced barrier precautions for the prevention transmission of multidrug-resistant organisms.
Documented under implementation of enhanced barrier precautions indicated Personnel Protection Equipment (PPE), is for EBP is only necessary when performing high- contact care activities. High contact care activities included providing hygiene, changing linen device care which included urinary catheter and wound care.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Beaconshire Nursing Centre in Detroit, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Detroit, MI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Beaconshire Nursing Centre or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.