Beardstown Health & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Beardstown Health & Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, patternF610Dec 13, 2021

  Based on record review and interview, the facility failed to investigate and report an allegation of sexual abuse, failed to identify residents potentially affected by the perpetrator and failed to develop interventions to prevent further sexual abuse, for one of four residents (R1) reviewed for abuse in a sample of 42. This resulted in the facility failing to develop a plan to monitor and supervise R1's sexually driven behaviors effectively and R1 groping R2's breast on 12/04/21. These failures have the potential to affect all 41 female residents (R2 - R42) that currently reside in the facility. These failures resulted in an Immediate Jeopardy. Findings include: The Immediate Jeopardy was identified on 12/09/21 at 1:00 pm. […]

• Immediate jeopardy, isolatedF600Dec 13, 2021

  Based on observation, record review and interview, the facility failed to identify a resident as high risk for sexual abuse and protect a resident's right to be free from sexual abuse and monitor increasing sexual behaviors directed towards female residents, for one of three residents (R2) reviewed for sexual abuse in a sample of 42. These failures resulted in facility staff observing R1 grope a cognitively impaired resident's breast (R2), after staff had reported to the Administrator (V10) on 11/13/21, that R1 was exhibiting increased sexually inappropriate behaviors that included touching/kissing female residents. These failures resulted in an Immediate Jeopardy. Findings include: The Immediate Jeopardy was identified on 12/09/21 at 1:00 pm. […]

• Actual harm, isolatedF760Aug 13, 2026

  Based on interview and record review the Facility failed to accurately transcribe a medication order for one of five Residents (R1) reviewed for medication administration in a sample of five. This failure resulted in R1 being transported to local emergency department and requiring admission to local hospital. This past non-compliance, which involved R1, occurred from 7/6/26 to 7/17/26.Findings include:The Facility Reconciliation on admission Protocol Policy, dated 7/3/23, documents: review all medications from the transferring facility and compare to the Physician Order Sheet; it is the responsibility of the staff to ensure the needs of a new admission and the needs are met and documentation is in place;R1's Hospital Discharge After Visit Summary, dated 6/28/26 through 7/6/26, documents… […]

• Actual harm, isolatedF697May 18, 2023

  Based on observation, interview, and record review, the facility failed to provide pain management for one of three residents (R34) reviewed for pain management in the sample of 27. This failure resulted in R34 experiencing severe pain and Physical Therapy shortening therapy with R34 on 5/15/23. Findings include: The Facility Policy: Management of Pain dated 4/4/12, documents Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. […]

• No harm, potential for more than minimal, widespreadF812Mar 3, 2022

  Based on observation, interview and record review, the facility failed to label food items, dispose of outdated foods and wash hands when coming into the kitchen and after handling dirty dishes and before handling clean dishes. This has the potential to affect all 45 residents living in the facility. Findings: The document Food Labeling and Dating, dated 2/22 documents, Labeling and dating food is important to assure foods are used in a timely manner. Proper food labeling includes: Name of product, date stored and in some cases, the time of the day; the food must be labeled and dated if it is removed from its original container. The document Food Storage Chart, dated 2/22, documents, Use by dates printed on label by the manufacturer applies until the product is opened. […]