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

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BEAVER HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are 125 surveys for this facility. Please select a date to view the survey results.

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BEAVER 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 two complaints, completed on June 6. 2024, it was determined that Beaver Healthcare and Rehabilitation Center 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:

483.10(e)(4)-(6) REQUIREMENT Choose/Be Notified of Room/Roommate Change:

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.

§483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

§483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement.

§483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.

Observations:

Based on review of facility policies, clinical record reviews and staff interviews it was determined that the facility failed to provide written notice, including reason for the change, prior to moving a resident to another room, for two of four residents reviewed (Residents R1, and R2).

Findings include:

Review of facility policy, "Transfer, Room to Room" , last reviewed 5/28/24, indicated that the following information should be recorded in the resident's medical record:
The date and time the room transfer was made.
The name and title of the individual(s) who assisted with the move.
All assessment data obtained during the move.
How the resident tolerated the move.
If the resident refused the move, the reason(s) why and the intervention taken.
The signature and title of the person recording the data.

Review of the clinical record revealed that Resident R1 was admitted to the facility on 12/10/23.

Review of Resident 1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/12/24, indicated diagnoses of high blood pressure, muscle weakness, and pain.

Review of Resident R1's census information revealed that on 3/2/24, the Resident R1 was moved from room 17-1 to room 16-2.

Review of Resident R1's clinical record revealed no documented evidence of the reason for the room changes, if the resident was notified prior to the room changes or if the resident was agreeable or given the opportunity to refuse the room changes.

Review of the clinical record revealed that Resident R2 was admitted to the facility on 6/1/24.

Review of Resident 2's medical record indicated diagnoses of diabetes, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and high blood pressure.

Review of Resident R2's census information revealed that on 6/4/24, the Resident R2 was moved from room 9-2 to room 18-2.

Review of Resident R2's clinical record revealed no documented evidence of the reason for the room changes, if the resident was notified prior to the room changes or if the resident was agreeable or given the opportunity to refuse the room changes.

During an interview on 6/6/24, at 11:56 a.m. Nursing Home Administrator confirmed that the facility failed to provide documentation regarding written notice, including reason for the change prior to moving residents to another room.

28 Pa. Code 201.14(a) Responsibility of licensee

29 Pa. Code 201.29(d)(j) Resident rights

Plan of Correction - To be completed: 07/01/2024

0559
R1 and R2 were notified and agreed prior to room change. Documentation was completed on R2. Family of R1 are aware of current room resident resides.
DON to educate nursing staff on facility Transfer: Room to Room Policy.
30 days look back will be conducted of room changes.
NHA/Designee will audit rooms changes weekly x 2 and monthly x1 to ensure resident notification of room changes and written notification.
Results of these audits will be reported and reviewed by the QAPI committee monthly for recommendations as needed.
Alleged date of compliance 07/01/2024.

483.15(a)(1)-(7) REQUIREMENT Admissions Policy:

§483.15(a) Admissions policy.
§483.15(a)(1) The facility must establish and implement an admissions policy.

§483.15(a)(2) The facility must-
(i) Not request or require residents or potential residents to waive their rights as set forth in this subpart and in applicable state, federal or local licensing or certification laws, including but not limited to their rights to Medicare or Medicaid; and
(ii) Not request or require oral or written assurance that residents or potential residents are not eligible for, or will not apply for, Medicare or Medicaid benefits.
(iii) Not request or require residents or potential residents to waive potential facility liability for losses of personal property.

§483.15(a)(3) The facility must not request or require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility. However, the facility may request and require a resident representative who has legal access to a resident's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident's income or resources.

§483.15(a)(4) In the case of a person eligible for Medicaid, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission or continued stay in the facility. However,-
(i) A nursing facility may charge a resident who is eligible for Medicaid for items and services the resident has requested and received, and that are not specified in the State plan as included in the term ''nursing facility services'' so long as the facility gives proper notice of the availability and cost of these services to residents and does not condition the resident's admission or continued stay on the request for and receipt of such additional services; and
(ii) A nursing facility may solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to a Medicaid eligible resident or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the facility for a Medicaid eligible resident.

§483.15(a)(5) States or political subdivisions may apply stricter admissions standards under State or local laws than are specified in this section, to prohibit discrimination against individuals entitled to Medicaid.

§483.15(a)(6) A nursing facility must disclose and provide to a resident or potential resident prior to time of admission, notice of special characteristics or service limitations of the facility.

§483.15(a)(7) A nursing facility that is a composite distinct part as defined in §483.5 must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under paragraph (c)(9) of this section.

Observations:

Based on review of facility policy, resident records, admissions documentation and staff interview it was determined that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for one of four sampled records (Resident R3).

Finding include:

The facility policy "Admissions Orientation" last reviewed 5/28/24, indicated that the facility shall provide each resident with a facility tour and an orientation of the facility's policies, programs, and services which includes but is not limited to residents rights and responsibilities.

Review of Resident R3 admission record indicated she was admitted on 5/5/24.

Review of Resident R3's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 5/12/24, indicated diagnoses of anorexia nervosa (an eating disorder causing patients to obsess about weight and what they eat), low potassium, and muscle weakness.

Review of Resident R3's admission packet (no date) did not indicate a signature from Resident R3 or a representative's signature, a date for review of the admission packet, or indicate that Resident R3 resident rights were reviewed.

Review of Resident R3s clinical nurse notes and admission documents did not indicate that Resident R4 or her representative reviewed resident rights and the admission packet.

During an interview on 6/6/24, at 11:45 a.m. Nursing Home Administrator confirmed that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for Resident R3 as required.

28 Pa Code: 201.18 (b)(2) Management.

28 Pa Code: 201.24 (a) Admission policy.

28 Pa Code: 201.19 (i) Resident rights.

Plan of Correction - To be completed: 07/01/2024

R3 has discharged from facility.
NHA to educate Admission/ Business Development Liaison, Social Worker and Business Office Manager on facility policy of reviewing resident admission rights and maintaining admission documentation.
30 day look back will be conducted to ascertain no other residents were affected.
NHA/Designee will audit new admissions weekly x 2 and monthly x 1 to ensure facility is reviewing resident admission rights with each resident and maintaining admission documentation.
Results of these audits will be reported and reviewed by the QAPI committee monthly for recommendations as needed.
Alleged date of compliance 07/01/2024.

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