Beloit Health and Rehabilitation Center (SFF) Abuse and Neglect Attorneys

Special Focus Facility (SFF) Beloit Health and Rehabilitation Center

Beloit Health and Rehabilitation CenterIn recent years, nursing home abuse lawyers have represented many more clients than normal who have been neglected and mistreated in nursing homes throughout Beloit. The Centers for Medicare and Medicaid Services (CMS) and the state of Wisconsin conduct routine investigations, surveys, and inspections of every nursing facility statewide. Their efforts help to identify serious violations, deficiencies, dangerous concerns, and health hazards.

In egregious cases, regulators might add the nursing home to the national Medicare deficiency watch list and designate the Home as a Special Focus Facility (SFF). These convalescent centers undergo additional surveys every year and unannounced inspections to investigate formally filed complaints. If the nursing home is unwilling or unable to make significant changes to the level of care they provide their residents, they might suffer serious monetary consequences.

It has been more than two years since regulators designated Beloit Health and Rehabilitation Center as a Special Focus Facility (SFF). Some serious concerns and violations involving this facility are detailed below.

Beloit Health and Rehabilitation Center

This Nursing Home is a Medicare/Medicaid-participating ‘for profit’ Center providing services to residents of Beloit and Rock County, Wisconsin. The 130-certified bed Facility is located at:

1905 W Hart Rd
Beloit WI 53511
(608) 365-2554

In addition to providing around the clock skilled nursing care, Beloit Health and Rehab also offers:

  • Short-term care
  • Long-term care
  • Infusion therapy
  • Post-operative care
  • Comprehensive wound care therapies
  • Renal disease services
  • Respiratory care
  • Digestive disease support
  • Cancer recovery services
  • Palliative care services

More Than $170,000 in Monetary Fines

State and federal nursing home regulatory agencies have the legal authority to levy monetary penalties against any convalescent facility identified to have serious violations and deficiencies. The fines are meant to notify the nursing staff that substandard care is never tolerated.

Over the last three years, regulators have been imposed for monetary penalties against Beloit Health and Rehabilitation Center. These penalties include a $90,253 fine on 01/13/2015, a $16,380 fine on 09/29/2015, a $33,411 fine on 09/19/2016 and a fine of $31,249 on 03/09/2017. Additionally, during the same time, Medicare denied a request for payment on three separate occasions occurring on 01/13/2015, 09/29/2015, and 03/09/2017, due to substandard care.

Current Nursing Home Safety Concerns

Information on every nursing home in the United States can be viewed on federal and state database websites including These government regulatory agencies regularly update their lists of health violations, opened investigations, safety concerns, incident inquiries, dangerous hazards, and filed complaints on facilities nationwide. Many families use this data to determine where to place a loved one who requires the highest level of hygiene assistance and skilled nursing care.

Currently, Beloit Health and Rehabilitation Center maintains an overall one out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, one out of five stars for staffing issues, and three out of five stars for quality measures. Over the last 36months, surveyors have investigated 18 formally filed complaints and three facility-reported issues that all resulted in citations. Some of the serious concerns, problems, deficiencies, and violations involving this facility include:

  • Failure to Report and Investigate Acts or Allegations of Abuse, Neglect or Mistreatment of Residents
  • In a summary statement of deficiencies dated March 9, 2017, a state surveying agency opened a formal complaint investigation against the nursing home to identify serious problems. The state surveyor noted that the facility “did not ensure all alleged violations involving mistreatment, neglect, exploitation, or abuse are reported immediately to the Administrator of the facility. Additionally, the facility did not report any of these incidents “to other officials [according to] State law through established procedures including the State Survey and Certification Agency.”

    The surveyor also noted that the facility “did not have evidence that all alleged violations are thoroughly investigated, [or that] further abuse was prevented while the investigation was in progress.” The deficiency by the nursing staff resulted in investigations that “were not reported to the Administrator and two other state officials within five working days of the incident and corrective action taken for [two grievance concerns involving three self-reports].”

    The incident was first documented went to residents of facility gave the first names of two staff members that “had an attitude. The facility did not re-interview the residents to identify what happened to determine if [either resident] had actual allegations of abuse. No staff or other residents were interviewed.”

    The state investigator reviewed the facility self-reported form that identified “an incident where a Certified Nursing Assistant (CNA) made an inappropriate, to [a resident. A second CNA] heard the comment and felt it was unprofessional and that [the resident] did not like it.” The witnessing Certified Nursing Assistant “did not immediately report it to her supervisor or the Administrator. The facility did not identify that she should have immediately reported the incident and took no corrective action with [the allegedly abusive CNA].”

    A separate incident was identified in the facility self-reported form documenting that a resident “was observed and his bed naked from the waist down and [another resident] was in her wheelchair next to the bed with the door closed. The facility only interviewed the resident on January 30, 2017, two days after the incident occurred on January 28, 2017.”

    The investigator noted that “there was no documentation from the staff person who observed the residents and the staff person was not identified in the Investigation Documentation. The two residents were questioned as to only what happened with no follow-up questions. The facility did not have evidence of inquiries of [either resident] as to why [the male resident] was naked from the waist down, what were either of their intentions or interests in the other resident, and the facility did not take any corrective action to ensure this does not reoccur.”

  • Failure to Provide Residents an Environment Free of Accident Hazards
  • In a summary statement of deficiencies dated September 11, 2017, a formal complaint inspection against the facility was opened by a state surveyor to investigate deficiencies. One deficiency identified included a failure to “ensure the environment was free from accident hazards as is possible when the facility did not reassess a grab bar enabler.” The deficient practice by the nursing staff involved one resident “reviewed for falls.”

    The incident involved a severely cognitively impaired resident who “fell from her bed and her left arm was [caught in] the grab bar device. The facility did not reassess the grab bar device to ensure the device was safe [for the resident] to use.” The state investigator reviewed the resident’s Nursing Notes documented at 1:30 AM on August 27, 2017. The documentation revealed that the resident “was found sitting on the floor, leaning on the bed with [her] legs bent under her. The residents left arm was wedged in the grab rail, and a one quarter inch indentation [was] noted to the left arm after straightening the arm out.”

    After the accident, the resident was “verbally yelling in pain [with] facial grimacing.” The resident was “unable to verbalize the location or rate of the pain.” The nurse practitioner was called, and the resident was sent to the emergency room.”

    As a part of the investigation, the surveyor spoke to the facility’s Assistant Director of Nursing on the afternoon of September 11, 2017 who said that “he could not find an assessment of the grab bar device for [the resident] after the fall.” The Assistant Director “stated there should have been an assessment of the grab bar device after the resident’s fall when she got her arm caught in the device.”

  • Failure to Provide Necessary Care and Services to Maintain a Resident’s Highest Well-Being
  • In a summary statement of deficiencies dated May 3, 2017, a formal complaint investigation was opened against the facility by a state surveyor to identify any violations or failures. The investigator concluded that the facility “did not ensure that each resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered Care Plan, and the resident’s choices, including but not limited to, the care of wounds.”

    The deficient practice by the nursing staff involved a resident who “was found to have alterations to skin integrity on her feet.” The resident’s physician treatment plan, including medication and dressing treatments, were not followed as ordered.” The deficiency was identified upon observation of the resident on the morning of May 3, 2017. While in the resident’s room, the surveyor noted that the resident’s “bed had a heel cushion, but there was no blanket riser, or blanket cradle noted on [the resident’s] bed to keep the blanket off her toes.”

  • Failure to Immediately Notify the Resident’s Doctor of a Serious Decline in Their Medical Condition That Jeopardizes Their Health and Well-Being
  • In a summary statement of deficiencies dated March 9, 2017, a complaint investigation against the facility was opened to help identify failures and violations. The state surveyor documented that the facility “did not ensure a physician was consulted [for an injured resident].” The surveyor documented that the resident’s “physician was not consulted when [the resident] had multiple falls and refused neuro-checks.”

    As a part of the investigation, the surveyor reviewed the resident’s Minimum Data Set (MDS) Assessment and medical records the documented that the resident “had a fall on November 3, 2016.” However, there was “no evidence in the record indicating a physician or physician extender was notified of the fall or that [the resident] refused neuro-checks related to the unwitnessed fall.” Again, on November 28, 2016, the resident had another unwitnessed fall. However, there “was no indication in the record that a physician or physician extender was notified of the fall.”

    An additional fall occurred on February 7, 2017. However, documentation revealed that there was “no evidence of a physician or physician extender notification for an unwitnessed fall or a refusal of neuro-checks.” Before concluding the investigation, the surveyor interviewed the facility’s Deputy Director of Nursing who stated “yes” when indicating that on November 20, 2015, a physician notification should have occurred.” The Deputy Director also indicated that a “physician notification was needed on November 3, 2016, related to notification of a fall and refusal of neuro-checks.”

  • Failure to Assist Residents Who Require Assistance with Activities Of Daily Living
  • In a summary statement of deficiencies dated September 19, 2016, a state surveyor opened a formal complaint against the facility to assist in identifying violations. The surveyor document at the facility “did not ensure a resident who was unable to carry Activities of Daily Living receives the necessary services to maintain good nutrition, grooming, and personal an oral hygiene.” The deficient practice involved five residents.

    In one incident, a resident “received bedpans and baths instead of showers and had a long way time to use the bedpan [before receiving] assistance to get off the bedpan.” Two other residents “did not receive assistance with bed baths or showers at least weekly and were not re-offered when they refused.” A fourth’s resident’s fingernails “were approximately ½ inch long, broken, jagged, and dirty.” This resident “did not receive the assistance needed to trim his long nails [and] did not receive the assistance needed for his showers and bed baths.” The resident’s wheelchair cushion was soiled, contained rotting food under the cushion, and had a very pungent odor.”

    A fifth resident “did not receive the assistance needed to cut his fingernails even after asking staff or assistance. Observations were made of another resident “with long, unkempt fingernails.” The surveyor showed the Director of Nursing the resident’s “room to observe the resident’s nails.” The Director “agreed [with the surveyor that] the nails needed to be cut, and they appeared unkempt and dirty [stating that] she would have someone cut them immediately.”

  • Failure to Ensure Residents Receive Proper Treatment to Prevent New Bedsores or Heal Existing Pressure Sores
  • In a summary statement of deficiencies dated May 12, 2016, a state survey team opened the complaint investigation against the facility to identify serious violations. The surveyor determined that the facility “did not ensure a resident having a pressure injury received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.” The deficient practice involved a resident who “was admitted to the facility without a pressure injury to her left posterior thigh.”

    The resident was “identified to be at risk for pressure injury development and [now has] a current avoidable pressure ulcer.” The resident’s “pressure ulcer prevention devices were observed not to be in place on May 12, 2016.” The resident was also “observed without dressing to her pressure injury, and the perineal area was not provided properly to prevent contamination to the [bedsore].”

    Before concluding the investigation, the surveyor interviewed the Director of Nursing who stated that “her expectation is related to following the Plan of Care for wearing boots at all times and heels float off the mattress.” The Director stated that “all pressure prevention items are to be in place according to their Plan of Care.” The Director also said that “she would expect heels to be floated and boots on to ensure prevention measures were in place.”

  • Failure to Develop, Implement and Enforce Programs That Investigate, Control and Keep Infections from Spreading
  • In a summary statement of deficiencies dated September 19, 2016, the state surveyor opened an investigation to identify violations. The surveyor documented that the facility “did not maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection.” The deficient practice by the nursing staff “had the potential to affect all 93 residents in the facility.

    The inspector stated that “the facility’s infection control program did not consistently calculate overall or site-specific incident rates of infection for monitoring and analysis.” The facility also “does not maintain a surveillance log of residents whose symptomatology may be indicative of infection but are not on antibiotic therapy, for monitoring and analysis. The facility does not update their surveillance logs [daily] to maintain current, up-to-date infections within the facility for daily monitoring analysis.” The investigator also documented that “linens were not handled in a manner to keep the linens clean during the laundry process.

Ready to File a Nursing Home Neglect Claim?

Is your loved one being mistreated, neglected or abused while residing at Beloit Health and Rehabilitation Center or any other nursing facility? If so, hiring an attorney could help. A lawyer working on your behalf can ensure your family is adequately compensated for your damages.

No upfront retainers or fees are required because personal injury attorneys accept every nursing home abuse claim for compensation through contingency fee arrangements. This agreement allows you to postpone paying for legal services until after your lawyer has successfully resolved your case through a negotiated out of court settlement or a jury trial award.


Client Reviews

Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric