Beatrice Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Beatrice Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 4, 2021

  LICENSURE REFERENCE NUMBER 12-006.09D7 Based on observation, interviews and record reviews, the facility failed to provide supervision to prevent accident and/or injury related to the elopement (when a patient leaves the facility/hospital when doing so may present an imminent threat to the patient's health or safety) for Resident 1 and the potential elopement risk for 2 residents (Residents 10 and 14). This had the potential to affect 14 residents- identified as at risk for wandering or elopement. […]

• Immediate jeopardy, isolatedF908Jan 4, 2021

  LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B3 Based on observation, record review and interviews, the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition to prevent elopement and entry to an unlocked garage and the potentially harmful chemicals and equipment to residents. This had the potential to affect 14 residents. The facility census was 68. Findings are: On 12/30/20 at 09:21AM, an observation of the exit doors completed with RN-F, revealed the SW exit door and SE exit did not close completely once opened. The observation revealed both of the doors remained open approximately an inch or less and would not close without staff pulling the doors shut. […]

• Actual harm, isolatedF689Mar 17, 2022

  Licensure Reference Number 175 NAC ,d+[DATE].09D7a Based on interview and record review, the facility failed to implement interventions to help prevent a fall with major injury for 1 (Resident 120) of 10 residents sampled. Total census was 61. Findings are: Record review of the facility's Fall Management System Policy with a revised date of ,d+[DATE] revealed it is the policy of the facility to provide each resident with appropriate assessments and interventions to prevent falls and to minimize complications if a fall occurred. Record review of Resident 120's Progress Notes dated [DATE] through [DATE] revealed Resident 120 had 8 falls on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. […]

• Actual harm, isolatedF867Mar 17, 2022

  LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interviews; the facility Quality Assessment and Performance Improvement (QAPI) program failed to identify ongoing issues relevant to F580, F610, F684, F692, F726, F760 and implement plans of action to identify and correct the deficient practice. The QAPI program failed to ensure repeated deficiencies at F609, F623, F689 and F880 were corrected and the correction maintained. The facility staff identified a census of 61. […]

• No harm, potential for more than minimal, widespreadF812Apr 9, 2025

  Licensure Reference Number 175 NAC 12-006.11C The facility failed to ensure hand hygiene was performed in the kitchen in order to prevent the spread of food borne illness. This had the potential to affect all the resident that reside in the facility. The facility census was 55. Findings are: Observation of meal preparation on 4/8/25 at 6:45 AM with Cook-A. Cook-A had gloves on when surveyor arrived. The chili recipe was on the prep table. Cook-A took hamburger out of the packages and placed in a pan and placed on the stove. At 6:49 AM Cook-A performed hand hygiene with soap and water for 13 seconds. Cook-A donned gloves and cut up onion and placed in another pan after measuring. At 6:52 AM Cook-A performed hand hygiene with soap and water for 10 seconds. […]