Pennsylvania Department of Health
BEAVER VALLEY HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BEAVER VALLEY HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are 158 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


BEAVER VALLEY HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to a complaint, completed on July 31, 2024, it was determined that Beaver Valley Healthcare and Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations

Plan of Correction:

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Observations:

Based on review of resident clinical records, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of three residents (Resident R1, and R9).

Findings Include:

A review of the facility policy "Transfer and discharge- 30 day" last reviewed 7/9/24, indicated a resident/representative will be notified in writing the reason for the transfer or discharge using the notice of transfer or discharge form, this includes sending a copy to the Office of the Long-Term Care Ombudsman

A review of Resident R1's clinical record indicates admission date of 7/12/24, with the diagnoses of Vascular Dementia with agitation (decline in thinking skills caused by reduced blood flow), Urinary tract infection (infection in the urinary system), and Hypertension (high blood pressure).

A review of Resident R1's clinical record revealed that the resident was transferred to the hospital on 7/15/24, and has not returned to facility.

A review of Resident R1's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of Long-Term Care Ombudsman for the hospitalization on 7/15/24.

A review of Resident R9's clinical record indicated the resident was admitted to the facility on 7/20/24, with the diagnosis of end stage renal disease (kidneys permanently fail to work), anemia (low iron in the blood), diabetes (high sugar in the blood).

A review of Resident R9's clinical record revealed that the resident was transferred to the hospital on 7/24/24, and has not returned to facility.

A review of Resident R9's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of Long-Term Care Ombudsman for the hospitalization on 7/24/24.

During an interview on 7/31/24, at 10:54 a.m. Social Service Director Employee E1 stated " I do not notify the ombudsman of a transfer to the hospital, I didn't know that they needed to be notified".

During an interview on 7/31/24, at 2:10 p.m. the Director of Nursing (DON) stated, "We do not send anything to the Ombudsman's Office" and confirmed that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of three residents.

28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.

Plan of Correction - To be completed: 08/21/2024

The Facility will inform the Office of Long-Term Care Ombudsman of the hospitalizations of R1 and R9.

A Transfer/Discharge Log will be developed to track all discharges and transfers and will be updated as needed. The Facility will provide a transfer notice to the representative of the Office of Long-Term Care Ombudsman Division per the facility policy, for all residents that transfer or discharge from the facility.

The Nursing Home Administrator/designee will educate the Social Worker on utilizing the Transfer/Discharge Log and on providing a transfer notice to the representative of the Office of Long-Term Care Ombudsman Division

The Nursing Home Administrator/designee will audit the Transfer/Discharge Log daily times fourteen (14) days and then weekly times 2 weeks.

Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met.

483.15(e)(1)(2) REQUIREMENT Permitting Residents to Return to Facility:

§483.15(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid
nursing facility services.
(ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.

§483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to permit the readmission of a hospitalized resident without providing evidence that the facility was not able to meet the resident's needs for one of three residents reviewed (Resident R1).

A review of the facility policy "Transfer and discharge- 30 day" last reviewed 7/9/24, indicated a resident and/or his or her representative (sponsor), will be given a thirty-day advanced notice of an impending transfer or discharge from facility. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge. The transfer is necessary for the resident ' s welfare and the resident ' s needs cannot be met in the facility.

A review of Resident R1's clinical record indicates admission date of 7/12/24, with the diagnoses of Vascular Dementia with agitation (decline in thinking skills caused by reduced blood flow), Urinary tract infection (infection in the urinary system), and Hypertension (high blood pressure).

A review of progress note 7/12/24, 12:23 p.m indicates resident arrived around 3:00 p.m., accompanied with family. Wander guard put on left leg. Family signed DNR. No complaints of pain at this time. Alert and Oriented x1 with confusion. Has been exit seeking throughout shift. Aide attempted to redirect resident, and resident yelled and tried to hit aide. Staff closed double doors, and resident did not attempt again this shift. Also, put resident on q 15 min checks. Has had increase behaviors, and attempted to do initial assessment, but resident refused. Stated "please don't touch me". Attempted three times throughout shift. Resident refused each time. Resident has been finding empty rooms and lays down for about 30 minutes at a time throughout shift. Orders verified and transcribed . Oriented to room, call light, and staff.

A review of progress note 7/13/24, 4:21 p.m. Resident has had increased behaviors this shift. Attempting to exit seek, redirecting resident back to hall. Resident keeps stating that she needs to have surgery. Reassuring resident no surgery will be performed. Resident requested to speak to family. Resident spoke with Sally and has had seem to relax a little more. Resident standing at nursing station at this time. Will continue q15 min checks and noted in physician binder about increased behaviors.

A review of progress note 7/15/24 5:28 p.m. Resident complained of shortness of breath, nausea, chest pain during activities. Escorted resident back to her room and obtained Vital Signs. Blood pressure 152/82, Heart rate-80, Temperature -98.1, Respirations-20, Oxygen saturation 97% on Room Air. Call made to sister to have permission to send to ER for eval. Physician notified. Medic Rescue on their way.

A review of progress note 7/15/24, 6:08 p.m. resident left with Medic Rescue via stretcher at this time.

A review of progress notes did not indicate that family/resident was not notified of Resident R1 requiring a secure unit or transfer to another facility or that that Resident R1 would not be returning to facility upon hospital transfer.

During an interview 7/31/24, 10:15 a.m. with Admission coordinator Employee E4 stated "from my understanding Resident R1 was not a fit for our building she was exit seeking and wandering, was not safe for her to be here, she needed a locked down unit".

During an interview 7/31/24, at 10:54 a.m. Social service director stated, "my normal process for a transfer would be to contact the family and work on a transfer to a memory care facility ".

During an interview 7/31/24, at 2:10 pm. The Nursing Home Administrator stated, "no formal notice of discharge was given to the family, the hospital was told the facility was not taking Resident R1 back at the time of transfer "and confirmed the facility failed to permit the readmission of a hospitalized resident without providing evidence that the facility was not able to meet the resident's needs for one of three residents reviewed.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(b)(1)(3) Management.

Plan of Correction - To be completed: 08/21/2024

The facility will permit the readmission of a resident unless the facility has provided evidence that the facility cannot meet the needs of the resident. If the resident's needs cannot be met and it is necessary for the welfare of the resident; a thirty (30) day advance notice of an impeding transfer /discharge will be given to the resident and/or the POA/responsible party.

The clinical team will discuss daily at clinical meeting all residents that have a change in condition and/or are exhibiting behaviors that put the resident or other residents at risk or endanger their overall welfare. The NHA or designee will audit that this discussion occurs daily for 14 days then weekly for 2 weeks. If the facility is no longer able to meet the resident's needs, a plan will be developed by the interdisciplinary team, involving the resident and/or POA/responsible party, to discharge or transfer to the appropriate setting to meet the resident's needs. A thirty (30) day discharge notice will be issued per facility policy.

The Nursing Home Administrator or designee will educate the Management team and the RN Supervisors on permitting a resident to readmit to the facility unless there is evidence that the facility cannot meet the needs of the resident and on the facility policy for thirty (30) day Discharge Notices.

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