Beech Tree Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF600Apr 11, 2024

  Based on facility policy review, medical record review, observation, and interview, the facility failed to protect residents from abuse and failed to identify abuse after resident-to-resident altercations for 6 residents (Residents #91, #40, #24, #73, #46 and #44) of 37 residents reviewed for abuse which resulted in injuries. Resident #91, with severe cognitive impairment, actively wandered into other resident rooms, and had no interventions implemented to protect the resident. Resident #40 had severe cognitive impairment and a history of resident-to-resident altercations and aggressive behaviors with no interventions implemented to protect other residents from abuse. […]

• Immediate jeopardy, patternF609Apr 11, 2024

  Based on facility policy review, medical record review, and interview, the facility failed to report an injury of unknown origin and resident to resident abuse to the local and state designated authority agencies for 7 of 37 (Residents #39, #24, #73, #46, #44, #91, and #40) sampled residents reviewed for abuse. Resident #39, a vulnerable and severely cognitively impaired, non-ambulatory resident, with bilateral leg contractures, sustained a left femur fracture with an undetermined cause. On 12/20/2023, Resident #39 verbalized increased pain and staff observed swelling in her right lower leg. She was sent to the emergency room (ER) and radiology tests identified a left femur fracture on 12/21/2023. […]

• Immediate jeopardy, patternF610Apr 11, 2024

  Based on facility policy review, medical record review, and interview, the facility failed to investigate an injury of unknown origin and three resident-to-resident altercations as the potential for abuse for 7 of 37 (Residents #39, #73, #24, #46, #44, #40, and #91) sampled residents reviewed for abuse. Resident #39, a vulnerable and severely cognitively impaired, non-ambulatory resident, with bilateral leg contractures, sustained a left femur fracture with an undetermined cause. On 12/20/2023, Resident #39 verbalized increased pain and staff observed swelling in her right lower leg. She was sent to the emergency room (ER) and radiology tests identified a left femur fracture on 12/21/2023. […]

• Immediate jeopardy, patternF656Apr 11, 2024

  Based on facility policy review, medical record review, observations and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for 9 residents (Residents #91, #40, #24, #73, #44, #46, #39, #20, and #78) of 37 residents reviewed for comprehensive care plans. The facility failed to address Resident #40's history of aggressive behaviors, with appropriate interventions. The facility failed to develop and implement a person-centered care plan related to Resident #91's wandering behaviors. […]

• Immediate jeopardy, patternF835Apr 11, 2024

  Based on facility policy review, job description review, facility documentation review, medical record review, and interview, the facility's Administration failed to provide effective leadership and oversight to ensure effective systems were in place to ensure residents were free from abuse, identify serious outcomes related to abuse, investigate allegations of abuse, determine a root cause analysis (RCA) for abuse, develop and implement person centered care plans, report allegations of abuse to the local and state designated authorities, and discuss concerns related to abuse in Quality Assurance Performance Improvement (QAPI) and Governing Body (GB) meetings. […]