Beloved Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF678Sep 24, 2021

  Based on interview and record review, the facility failed to ensure the facility transporters, who transported one sampled resident (Resident #3), 13 additional residents (Resident #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20), and five closed record residents (Resident #51, #52, #55, #56, and #57) in the facility van, all of which had elected a full code status, were properly trained and certified in CPR. The facility failed to implement facility policy to have systems in place to ensure there was an adequate number of staff certified in cardiopulmonary resuscitation (CPR-process of providing rescue ventilation and chest compressions to maintain circulation of blood) present in the facility, 24 hours a day seven days a week. […]

• Immediate jeopardy, isolatedF689Apr 4, 2025

  Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1), who was identified as at risk for elopement, in a review of six sampled residents, did not leave the facility without staff knowledge. Staff failed to ensure an interior, alarmed, coded double door, as well as the front entrance door alarms were activated and secured on 3/27/25. The resident exited the facility through the interior, alarmed, coded double doors, leading from the dining room to the facility front entrance and exited through the front entrance door without the alarm sounding and without staff knowledge. He/She walked one mile to a convenience store across four lanes of traffic and fell by the roadway. […]

• Immediate jeopardy, isolatedF684Aug 2, 2024

  Refer to Event ID C0JV13 Based on interview and record review, the facility failed to provide care per policy or in accordance with professional standards of practice to six insulin dependent diabetic residents of 29 sampled residents, (Resident #1, #11, #6, #17, #14, and #16). The facility failed to notify Resident #1's physician when the resident experienced hypoglycemic (low blood sugar) and hyperglycemic (high blood sugar) blood glucose readings and was documented as refusing blood glucose tests and insulin. Staff failed to obtain parameters for when to notify the physician of hypoglycemic blood glucose readings. The resident's blood glucose readings ranged from 30 to 537 milligrams per deciliter (mg/dl) (normal range 80-120 mg/dl). […]

• Immediate jeopardy, isolatedF689Jun 18, 2024

  Based on interview and record review, the facility failed to provide adequate supervision for two residents (Resident #5 and #7) in a review of 12 sampled residents. Staff failed to monitor Resident #5 who was left outside from approximately 10:00 A.M. to 12:00 P.M. The resident sat in a wheelchair in the facility courtyard in direct sunlight with temperatures of 87 degrees Fahrenheit (F) and a 91 degree F heat index. The resident was assessed to have altered mental status, was difficult to arouse, and had low oxygen saturation. The resident was sent to the hospital where he/she was admitted with diagnoses of encephalopathy (chemical imbalance in the blood caused by illness) and possible heat stroke (severe heat-related illness that occurs when the body can not regulate its temperature). […]

• Immediate jeopardy, isolatedF684Mar 28, 2024

  Based on interview and record review, the facility failed to provide care per policy or in accordance with professional standards of practice to six insulin dependent diabetic residents of 29 sampled residents, (Resident #1, #11, #6, #17, #14, and #16). The facility failed to notify Resident #1's physician when the resident experienced hypoglycemic (low blood sugar) and hyperglycemic (high blood sugar) blood glucose readings and was documented as refusing blood glucose tests and insulin. Staff failed to obtain parameters for when to notify the physician of hypoglycemic blood glucose readings. The resident's blood glucose readings ranged from 30 to 537 milligrams per deciliter (mg/dl) (normal range 80-120 mg/dl). […]