Beloit Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Oct 20, 2022

  Based on observation, interview and record review, the facility did not implement professional standards of practice to ensure that a resident did not develop a pressure injury (PI) and that the resident received necessary treatment and services to promote healing and prevent infection of the pressure injury for 1 of 4 residents sampled for pressure injuries (Resident 6). R6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 had a care planned intervention for an air mattress, the facility removed the air mattress without evidence of reassessing R6's risk for developing a PI before removal. R6 developed a PI after the air mattress was removed. […]

• Actual harm, isolatedF760Sep 12, 2024

  Based on interview and record review, the facility did not ensure that residents were free of any significant medication errors for 1 of 1 resident (R57) reviewed for significant medication errors. R57 did not receive scheduled insulin at 8:00AM on 7/24/24 and did not have blood glucose monitoring in place. R57 was hospitalized on the evening of 7/24/24 with acute hyperglycemia (a medical emergency that occurs when blood sugar levels are extremely high) requiring treatment with insulin drip (administration of insulin through intravenous line.) Evidenced by: Facility policy entitled Medication Administration, dated 05/2024, states in part: Policy: Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice . 20. […]

• Actual harm, isolatedF881Sep 12, 2024

  Based on interview and record review, the facility did not ensure they followed their Antibiotic Stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 6 sampled residents (R16 and R34) and 1 supplemental resident (R612) reviewed for antibiotic stewardship. R16 is being cited at severity level 3 (actual harm). R34 and R612 are being cited at severity level 2 (potential for more than minimal harm). The facility did not follow Standards of Practice for Antibiotic Stewardship: R16 has a history of antibiotic resistance and was prescribed antibiotics without meeting criteria. […]

• Actual harm, isolatedF580Jun 15, 2023

  Based on interview and record review, the facility did not immediately consult with a resident's physician when there was a need to alter treatment for 1 of 7 residents (R63) that resulted in actual harmy, and 1 of 7 residents (R61) that had potential for minimal harm. The facility did not consult with R63's Medical Doctor (MD) per Physician Orders and as her condition changed resulting in actual harm when R63 was hospitalized and aggressive diuresis. Evidenced by: Facility policy, entitled Notifications of Change, date implemented 12/2022, states in part .the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring… […]

• Actual harm, isolatedF883Jun 15, 2023

  Based on record review and interview, the facility did not offer and/or administer the influenza immunization to each resident, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza and immunization for 1 of 6 (R64) residents reviewed for immunizations that resulted in actual harm, and 2 of 6 residents (R34 and R27) reviewed for immunizations that resulted in the potential for harm. R64 consented to have the influenza immunization upon admission to the facility. […]