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Deficiency Records for Beeghly Oaks Center For Rehabilitation and Healing
A list of the most recent deficiencies for Beeghly Oaks Center For Rehabilitation and Healing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Beeghly Oaks Center For Rehabilitation and Healing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-09-25 | 2024-10-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-09-25 | 2024-10-21 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-09-25 | 2024-10-21 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-09-25 | 2024-10-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-25 | 2024-10-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-09-25 | 2024-10-21 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-09-25 | 2024-10-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-09-25 | 2024-10-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-09-25 | 2024-10-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-25 | 2024-10-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-09-25 | 2024-10-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-09-25 | 2024-10-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-09-25 | 2024-10-21 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-09-25 | 2024-10-21 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-09-25 | 2024-10-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-09-25 | 2024-10-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-09-25 | 2024-10-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-09-25 | 2024-10-21 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-09-25 | 2024-10-21 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-09-25 | 2024-10-21 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-09-25 | 2024-10-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-25 | 2024-10-21 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-09-25 | 2024-10-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-09-25 | 2024-10-21 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-09-25 | 2024-10-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-25 | 2024-10-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-09-25 | 2024-10-21 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-09-25 | 2024-10-21 | N |
| Keep all essential equipment working safely. | Health | 2024-09-25 | 2024-10-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-25 | 2024-10-21 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-09-25 | 2024-10-21 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-09-10 | 2024-10-21 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-09-10 | 2024-10-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-09-10 | 2024-10-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-09-10 | 2024-10-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-09-10 | 2024-10-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-09-10 | 2024-10-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-10 | 2024-10-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-09-10 | 2024-10-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-09-10 | 2024-10-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-09-10 | 2024-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-09-10 | 2024-10-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-09-10 | 2024-10-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-06-05 | 2024-06-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-05 | 2024-06-13 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-04-24 | 2024-05-08 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-04-24 | 2024-05-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-08 | 2023-11-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-08 | 2023-11-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-08 | 2023-11-27 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-08 | 2023-11-27 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-08 | 2023-11-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-08 | 2023-11-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-14 | 2023-06-30 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-14 | 2023-06-30 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-06-14 | 2023-06-30 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-06-14 | 2023-06-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-31 | 2023-06-07 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-31 | 2023-06-07 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-02 | 2023-05-17 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-02 | 2023-05-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-02 | 2023-05-17 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-05-02 | 2023-05-17 | Y |
| Post nurse staffing information every day. | Health | 2023-05-02 | 2023-05-17 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-05-02 | 2023-05-17 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-05-02 | 2023-05-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-16 | 2023-01-13 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-12-16 | 2023-01-13 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-12-16 | 2023-01-13 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-16 | 2023-01-13 | N |
| Respond appropriately to all alleged violations. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-16 | 2023-01-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide or arrange emergency care by a doctor 24 hours a day. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-12-16 | 2023-01-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-16 | 2023-01-13 | N |
| Dispose of garbage and refuse properly. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-12-16 | 2023-01-13 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-12-16 | 2023-01-13 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2022-12-16 | 2023-01-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-16 | 2023-01-13 | N |
| Use approved construction type or materials. | Fire Safety | 2022-11-29 | 2023-01-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-29 | 2023-01-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-29 | 2023-01-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-29 | 2023-01-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-29 | 2023-01-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-29 | 2023-01-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-29 | 2022-10-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-29 | 2022-10-11 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-08-08 | 2022-08-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-08 | 2022-08-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-08 | 2022-08-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-08 | 2022-08-23 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-08-08 | 2022-08-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-08 | 2022-08-23 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-08 | 2022-08-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-08 | 2022-08-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-11 | 2022-04-21 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-11 | 2022-04-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-11 | 2022-04-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-01 | 2022-02-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-07 | 2022-02-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-07 | 2022-02-02 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-12-07 | 2022-02-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-18 | 2022-02-02 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-11-18 | 2022-02-02 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-12-07 | 2021-12-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-07 | 2021-12-28 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-01-30 | 2020-03-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-30 | 2020-03-05 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-01-30 | 2020-03-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-30 | 2020-03-05 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2020-01-30 | 2020-03-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-30 | 2020-03-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-30 | 2020-03-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-28 | 2020-03-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-28 | 2020-03-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-28 | 2020-03-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-30 | 2020-02-12 | N |
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