Beeghly Oaks Center for Rehabilitation & Healing

In the surveyor’s words

From the most serious findings on record at Beeghly Oaks Center for Rehabilitation & Healing, in the surveyor’s own words.

• Actual harm, isolatedF684Sep 25, 2024

  Based on observation, interview, record review, review of the Prehospital Care Report Summary, and review of the facility policy the facility failed to ensure Resident #7 was provided timely and appropriate care and services to properly evaluate and treat a fall, Resident #7 was not administered pain medication for complaints of severe pain after the fall and was not transported to the hospital timely after the fall. This affected one resident (#7) of six residents reviewed for accidents. The facility census was 102. Actual Harm occurred on 06/17/24 at 7:55 P.M. […]

• Actual harm, isolatedF686Sep 25, 2024

  Based on observation, interview, record review, and review of the facility policy the facility failed to ensure individualized care planned interventions were developed and followed to prevent Resident #32 and Resident #1 from developing in-house pressure ulcers and failed to ensure the pressure ulcers were timely identified, properly treated, and interventions were initiated to promote healing. Additionally, the facility failed to ensure Resident's #24, #29 and #71 had pressure ulcer risk evaluations completed quarterly, failed to ensure Resident #81 had skin checks and treatments completed as ordered, and failed to ensure Resident #81's physician orders and care planned interventions were followed for heel protectors. […]

• Actual harm, isolatedF689Sep 25, 2024

  Based on observation, record review, Emergency Medical Services (EMS) documentation, hospital record review, facility policy review, and interview the facility failed to develop and implement an effective, comprehensive and individualized fall prevention program for Resident #197 to decrease the resident's risk of repeated falls. The facility failed to ensure Resident #197 was provided timely assistance with toileting and failed to ensure the resident was not left unattended in a chair in the activity room without proper footwear and clothing resulting in a fall on 08/26/24 with multiple fractures. The facility also failed to ensure accurate and complete fall risk assessments were completed for Resident #61. […]

• Actual harm, isolatedF697Sep 25, 2024

  Based on observation, interview, record review, local police department call detail report, self-reported incident (SRI) review, review of prehospital care report summary, emergency department (ED) provider note, and facility policy review the facility failed to develop and implement an effective and individualized pain management program for Resident #147 following a significant change in condition resulting in severe pain that was not treated timely. This affected one resident (#147) of three residents reviewed for pain. The facility census was 102. Actual Harm occurred on 09/04/24 at 3:42 P.M. […]

• Actual harm, isolatedF686Dec 16, 2022

  Based on observation, record review, review of facility policy and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention and treatment program to ensure interventions were initiated timely to prevent the development of pressure ulcers and/or to ensure adequate treatments were in place to promote healing. This affected four residents (Resident #9, #10, #20, and #81) of five residents reviewed for pressure ulcers. The facility census was 83. […]