Beverly Hills Rehabilitation Centre

In the surveyor’s words

From the most serious findings on record at Beverly Hills Rehabilitation Centre, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 6, 2024

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had history of falls and a diagnosis of dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning that interferes with doing everyday activities) received the necessary care needs and services by failing to: -Identify and develop an appropriate care plan for Resident 1's dementia through an Interdisciplinary Team (IDT) approach, with appropriate interventions including implementation of individualized care and maximizing the resident's safety. -Implement a bed alarm or provide supervision for Resident 1. […]

• Actual harm, isolatedF744Nov 6, 2024

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had history of falls and a diagnosis of dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning that interferes with doing everyday activities) received the necessary care needs and services by failing to: -Identify and develop an appropriate care plan for Resident 1's dementia through an Interdisciplinary Team (IDT) approach, with appropriate interventions including implementation of individualized care and maximizing the resident's safety. -Implement a bed alarm or provide supervision for Resident 1. […]

• Actual harm, isolatedF689Mar 22, 2023

  Based on interview and record review, the facility failed ensure one of three residents (Resident 1), who was assessed as a high fall risk, was not left seated on the edge of a low air loss (LAL - a pressure-relieving mattress used to prevent and treat bed sores) mattress bed unsupervised. This deficient practice resulted in Resident 1 falling on October 14, 2022, at 7:45 a.m., sustaining a fracture (break in a bone) to left lower leg. Resident 1 was transferred and admitted to a General Acute Care Hospital (GACH) on October 15, 2022. […]

• Actual harm, isolatedF600Dec 29, 2022

  Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by Certified Nursing Assistant 1 for one of two sampled residents (Resident 1). On 10/30/2022, Certified Nurse Assistant (CNA) 1 hit Resident 1 in the head and groin. As a result, Resident 1, who was incontinent of bowel and bladder (no control over urination or defecation) had continued pain and was tearful when remembering the incident. Findings: A review of Resident 1's admission record indicated the facility admitted Resident 1 on 5/25/2022 with diagnoses including difficulty in walking, muscle weakness, diabetes (high blood sugar) and bed sores. […]

• Actual harm, isolatedF689Apr 29, 2022

  Based on interview and record review the facility failed to ensure one of two sampled residents (Resident 1), who was confused, restless, and was a risk for elopement (a resident who leaves the facility when doing so may present an imminent threat to the resident's health and safety because the resident is too impaired to make a decision to leave), was provided with a safe environment and supervision as per the resident ' s assessment and plan of care. As a result, on 2/28/2022, at 9:45 p.m., Resident 1 jumped out of the window of his room (located on a second floor) sustaining multiple fractures, broken teeth, skin cuts, and brain bleeding. […]