Inspection visit

Health inspectionMay 30, 2025

BEAVER HEALTHCARE AND REHABILITATION CENTERCMS #39510919 citations on this visit

19 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 19 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Code of Federal Regulations, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain residents were free from mental abuse, including abuse facilitated or enabled through the use of technology for two of four residents reviewed (Residents R13 and R21). Findings include: Review of the Code of Federal Regulations (CFR) §483.5 abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of admission record indicated Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/11/25, indicated the diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), hypertension (the force of the blood against the artery walls is too high), and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Review of admission record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's MDS dated [DATE], indicated the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), hypertension, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of facility provided documentation dated 10/27/24, indicated a photo and video was taken of Resident R13 and Resident R21 without the residents' knowledge. The photo and video were taken by a facility staff member Activities Employee E5 and transmitted via text message to another facility staff member, Activities Employee E6. Activities Employee E6 then transmitted the photo and video via text message to another resident, Resident R25. Photo and video were taken due to allegation of Resident R13 and Resident R21 taking belongings that did not belong to them. Page 1 of 31 395109 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0600 Level of Harm - Minimal harm or potential for actual harm Review of Activities Employee E5's witness statement dated 11/1/24, at 1:35 p.m. indicated on Sunday 10/27/24, around 4:20 p.m. there were residents in the dining room taking things off the back table that were left over from the Alzheimer sale and pictures and videos were taken of those residents, they were sent to a coworker, and the coworker who received the message sent the photo and video to another resident, Resident R25. Residents Affected - Few Review of witness statement dated 11/1/24, at 1:34 p.m. indicated Activities Employee E6 was sent a video and pictures of Resident R13 and Resident R21 allegedly taking stuff. Activities Employee E6 indicated the photo and videos were transmitted to Resident R25's phone so resident could check on the items that were in the dining room at that time. Resident R25 hosts an event for Alzheimer's and wanted Activities Employee E6 to check on the items. Review of Resident R25's witness statement indicated Resident R25 received photo and videos via text message from staff member Activities Employee E6. Resident R25 showed the Nursing Home Administrator the photo and videos of Resident R13 and Resident R21 on the resident's phone that were sent by Activity Employee E6. Resident R25 deleted the photo and videos from the resident's phone and refused to give any further statements and did not want to be involved. Review of facility documentation of interview with the Nursing Home Administrator and Resident R13 on 10/30/24, indicated Resident R13 did not recall staff member Activity Employee E5 taking a photo or video and indicated Resident R13 gave no permission for photo or video to be taken. Review of Facility documentation of interview with the Nursing Home Administrator and Resident R21 on 10/30/24, indicated Resident R21 did not recall staff member Activity Employee E5 taking a photo or video while in the dining area. Resident R21 indicated Activities Employee E5 did not ask resident to take a photo. Resident R21 indicated being in the dining room looking at items left over from the Alzheimer's sale. Interview on 5/29/25, at 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to make certain residents were free from mental abuse, including abuse facilitated or enabled through the use of technology for two of four residents reviewed (Residents R13 and R21). 28 Pa. Code 201.18(b)(1)(2)(3) Management. 28 Pa. Code 201.29 Responsibility of licensee. 28 Pa. Code 211.10(a)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services. 395109 Page 2 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medication for two of four residents (Resident R17, and R45). Findings include: Review of facility Psychotropic Medication Use dated 3/10/25, indicated that residents will not receive medications that are not clinically indicated to treat a specific condition. Drugs in the following categories are considered psychotropic medication and are subject to prescribing, monitoring, and review requirements: Anti-psychotics, Anti-depressants, Anti-anxiety, and Hypnotics. Psychotropic medications are not prescribed or given on a PRN (as needed) basis unless medication is necessary. PRN orders for psychotropic medications are limited to 14 days. Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/30/25, indicated diagnoses anxiety, hypokalemia (deficiency of potassium in the bloodstream), and spina bifida (a defect that occurs when the spinal cord and bones of the spine do not close completely during pregnancy). Review of Resident R17's physician order dated 4/23/25, indicated to administer Hydroxyzine (a psychotropic medication that can be used to treat anxiety), give 10 milligrams every four hours PRN for anxiety. Review of Resident R17's physician order failed to include a 14 day stop date and there was no documented rationale by the physician for the medication to extend past 14 days for Resident R17's Hydroxyzine. Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE]. Review of Resident R45's MDS dated [DATE], indicated diagnoses anxiety, high blood pressure, and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of Resident R45's physician order dated 5/3/25, indicated to administer Hydroxyzine, give 10 milligrams every six hours PRN for anxiety. Review of Resident R45's physician order failed to include a 14 day stop date and there was no documented rationale by the physician for the medication to extend past 14 days for Resident R45's Hydroxyzine. During an interview on 5/2925, at 9:54 a.m. Director of Nursing confirmed that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for two of four residents (Resident R17, and R45). 395109 Page 3 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0605 28 Pa. Code 211.2(d)(3) Medical director Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10(a) Resident care policies Residents Affected - Few 395109 Page 4 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of the Code of Federal Regulations, personnel records and staff interview, it was determined that the facility failed to conduct a criminal background check prior to working on the nursing unit for one out of five personnel records (Nurse Aide (NA) Employee E7). Residents Affected - Few Findings include: Review of the Code of Federal Regulations §483.12(b) the facility must develop and implement policies and procedures that include the following component: Screening: The facility must have written procedures for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit abuse, neglect, and exploitation of resident property, and consistent with the applicable requirements at §483.12(a)(3). This includes attempting to obtain information from previous employers and/or current employers and checking with the appropriate licensing boards and registries. §483.12(b)(3) Include training as required. Review of NA Employee E7 personnel record on 5/29/25, indicated a start date of 3/17/25. The record indicated NA Employee E7 had a criminal background check ran on 5/28/25. During an interview on 5/30/25, at 9:25 a.m. the Nursing Home Administrator confirmed NA Employee E7's criminal background check was not conducted prior to the start date as required for one out of five personnel records (NA Employee E7). 28 Pa Code: 201.14(b) Responsibility of licensee 28 Pa Code: 201.19(8) Personnel policies and procedures 28 Pa Code: 201.29 Responsibility of licensee 395109 Page 5 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain timely documentation of the admission agreement for four of four residents (Resident R2, Resident R12, R33, and R56) and failed to ensure residents had the capacity to understand the terms of the admission agreement for three of four residents (Residents R12, R33, and R56). Findings include: Review of the facility policy admission Agreement dated 3/10/25, indicated all residents have a signed and dated admission agreement on file. At the time of admission, the resident (or their representative) must sign an admission agreement (contract). Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R2's admission record indicated and admission date of 12/24/21. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/16/25, indicated the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), multiple sclerosis (immune system eats away at protective covering of nerve cells), and hypertension (the force of the blood against the artery walls is too high). Section C0500 BIMS score of 15. Interview with the Nursing Home Administrator on 5/29/25, at 12:29 p.m. indicated Resident R2 did not have an admission agreement completed on admission, so the facility had it completed with Resident R2 today (5/29/25). Review of Resident R12's admission record indicated and admission date of 9/16/24. Review of Resident R12's MDS dated [DATE], indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), hypertension, and depression. Section C0500 BIMS score of five - severe impairment. Interview with the Nursing Home Administrator on 5/29/25, at 1:32 p.m. indicated Resident R12 did not have an admission agreement completed on admission date of 9/16/24, and that Resident R12 did not 395109 Page 6 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0620 have the capacity to understand the terms of the admission agreement. Level of Harm - Minimal harm or potential for actual harm Review of Resident R33's admission record indicated and admission date of 4/9/25. Residents Affected - Some Review of Resident R33's MDS dated [DATE], indicated the diagnoses of dementia, hypertension, and depression. Section C0500 BIMS score of five - severe impairment. Review of Resident R33's census report indicated the following admission and discharge date s: Admit 3/31/23, with discharge 4/8/23. Admit 10/19/23, with discharge 10/23/23. Admit 3/22/24, with discharge 3/31/24. Admit 7/19/24, with discharge 7/30/24. Admit 11/16/24, with discharge 11/22/24. Admit 3/21/25, with discharge 3/26/25. Admit 4/9/25, with discharge 4/20/25. Admit 5/1/25, with discharge 5/5/25. Admit 5/16/25. Interview with the Nursing Home Administrator on 5/29/25, at 1:34 p.m. indicated the facility failed to complete an admission agreement with each admission to the facility and that Resident R33 did not have the capacity to understand the terms of the admission agreement. Review of Resident R56's admission record indicated and admission date of 5/8/25. Review of Resident R56's MDS dated [DATE], indicated the diagnoses of anemia, hypertension, and stroke (damage to the brain from an interruption of blood supply). Section C0500 BIMS score of eleven moderately impaired. Interview with the Nursing Home Administrator on 5/29/25, at 1:32 p.m. indicated Resident R12 did not have an admission agreement completed on admission date of 5/8/25, and that Resident R56 did not have the capacity to understand the terms of the admission agreement. Interview on 5/29/25, at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to maintain timely documentation of the admission agreement for four of four residents (Resident R2, Resident R12, R33, and R56) and failed to ensure residents had the capacity to understand the terms of the admission agreement for three of four residents (Residents R12, R33, and R56). 395109 Page 7 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0620 28 Pa Code: 201.18(b)(1)(3)Management. Level of Harm - Minimal harm or potential for actual harm 28 Pa Code: 201.24(a) admission policy. 28 Pa Code: 201.29(a)(b) Resident Rights Residents Affected - Some 395109 Page 8 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of three residents (Resident R3 and R42). Residents Affected - Few Findings include: Review of facility policy Oxygen Administration last reviewed 3/10/25, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. Steps include but not inclusive to: Check the mask, tank, humidifying jar, etc., to be sure they are in good working order. Periodically re-check water in humidifying jar. Review of facility policy Departmental (Respiratory Therapy) Prevention of Infection last reviewed, 3/10/25, indicated the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment. Infection control considerations related to oxygen administration include but not inclusive to: Check water level of any prefilled reservoir every forty-eight hours. Change pre-filled humidifier when the water level becomes low. Change the oxygen cannula and tubing every seven days, or as needed. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/5/25, indicated diagnoses of heart failure (heart can ' t pump blood the way it should), coronary artery disease (CAD- buildup of plaque in the arteries that block blood supply to heart), and anxiety. Review of a physician order dated 8/1/24, indicated to start oxygen at 3 liters per minute (lpm) for shortness of breath. The orders failed to include instructions for oxygen maintenance. During an observation and interview completed on 5/27/25, at 1:10 p.m. Resident R3 was sitting in her room, an oxygen concentrator was sitting behind Resident R3 not in use. Upon asking Resident R3 concerning oxygen use, Resident R3 replied I use it when I need it further observation revealed the humidifier was labeled with the date of 3/9/25, and the oxygen tubing failed to be labeled with a date. During an interview completed on 5/27/25, at 1:13 p.m. Licensed Practical Nurse (LPN) Employee E8 confirmed the humidifier was labeled with the date of 3/9/25, and the oxygen tubing failed to be labeled with a date as required. Review of the clinical record indicates Resident R42 was admitted to the facility on [DATE]. Review of Resident R42's MDS dated [DATE], indicated the diagnosis of chronic obstructive pulmonary disease (COPD-lung condition caused by damage to the airways that restricts breathing), anemia (low iron in the blood), and hypertension (high blood pressure). Review of Resident R42's physician orders dated 3/13/25, indicated oxygen at 2 to 4 lpm, via nasal cannula (thin flexible tubing used to deliver oxygen) as needed for shortness of breath, keep oxygen saturation above 92 percent. Check oxygen saturation each shift. 395109 Page 9 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0695 Level of Harm - Minimal harm or potential for actual harm Review of Resident R42's physician orders dated 3/16/25, indicated to change oxygen tubing and cannister every Sunday on the night shift. During an observation completed on 5/27/25, at 1:32 p.m. Resident R42 was sitting in the dining room her oxygen was on via nasal cannula, the oxygen tubing failed to be labeled with a date. Residents Affected - Few During an interview completed on 5/27/25, at 1:33 p.m. Registered Nurse (RN) Employee E9 confirmed that the oxygen tubing failed to be labeled with a date as required. During an interview completed on 5/28/25, at 2:50 p.m. the Nursing Home Administrator confirmed that the facility failed to provide appropriate respiratory care for two of three residents (Resident R3 and R42). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services 395109 Page 10 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for three out of three nurse aide personnel records (Nurse Aides (NA) Employee E10, NA Employee E11, and NA Employee E12). Residents Affected - Some Findings include: Review of facility policy In-Service Training, Nurse Aide dated 3/10/25, indicated the facility completes a performance review of nurse aides at least every 12 months. Review of NA Employee E10's personnel record indicated a hire date of 4/11/18. Review of NA Employee E11's personnel record indicated a hire date of 8/27/89. Review of NA Employee E12's personnel record indicated a hire date of 9/17/17. Review of personnel records did not include annual performance evaluations based on the date of hire for NA Employee E10, NA Employee E11, and NA Employee E12. Interview on 5/28/25, at 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to complete annual performance evaluations based on date of hire for NA Employee E10, NA Employee E11, and NA Employee E12. 28 Pa Code: 201.18 (b)(1)(3) Management 28 Pa Code: 201.19(2) Personnel policies and procedures. 395109 Page 11 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRR) were completed and documented by the consultant pharmacist for one of four residents (Resident R44). Findings include: The facility policy Consultant Pharmacist Provider Requirements reviewed 3/10/25, indicated the consultant pharmacist will establish a system whereby observations and recommendations regarding resident drug therapy are communicated to those with authority to implement or respond to the recommendations in an appropriate and timely fashion. Reviewing the medication drug regimen of each resident at least monthly and documenting the review and findings in the resident ' s medical record. Review of Resident R44's admission record indicated resident was admitted to the facility on [DATE]. Review of Resident R44's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/9/25, indicated the diagnoses of high blood pressure, coronary artery disease (damage or disease in the heart's major blood vessels), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R44's clinical record on 5/29/25, at 10:45 a.m. failed to have monthly medication review documentation in the medical record completed by the consult pharmacist for Resident R44 monthly from April 2024, through May 2025. Review of Resident R44's clinical record on 5/29/25, at 11:04 a.m. indicated the following: April 2024 - facility failed to provide the MRR May 2024- facility failed to provide the MRR June 2024- facility failed to provide the MRR August 2024- facility failed to provide the MRR September 2024- facility failed to provide the MRR October 2024 - facility failed to provide the MRR November 2024- facility failed to provide the MRR December 2024- facility failed to provide the MRR April 2025- facility failed to provide the MRR During an interview on 5/29/25, at 12:47 p.m. the Director of Nursing (DON) stated, The reason why 395109 Page 12 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there is no pharmacist documentation in the medical record is because they don't have computer access and I can't find any MRR's for the above dates. During an interview on 5/29/25, at 1:05 p.m. the DON confirmed that the facility failed to ensure Medication Regimen Reviews were completed and documented by the consultant pharmacist for one of four residents (Resident R44). 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.9 (k) Pharmacy services. 395109 Page 13 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms (back hall medication room). Findings include: Review of the facility policy Medication Labeling and Storage last reviewed 3/10/25, indicated medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The medication label includes, at a minimum: the medication name, prescribed dose, strength, expiration date, residents name, route of administration and appropriate instructions and precautions. If medications containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. During an observation on 05/27/25, at 5:46 p.m. the back hall medication room contained the following: The medication room counter contained: 1. A blue tote bag sitting on counter that contained a personal cell phone and food items. 2. A green backpack The area under the sink contained an unlocked green tackle box with the following medications: 2 Benadryl injectable 50 milligram (mg) 1 cubic centimeter (cc) syringes (used to treat life threatening reactions) with the expiration date of 3/25. 2 Glucagon injectable 1 mg unit (used to trat low blood sugar) with the expiration date 4/25. 4 Lasix injectable 2 ml vials (treats fluid retention) with the expiration date of 8/24. 1 Narcan 1mg syringe (used to treat an opioid overdose) with the expiration date of 2/25. 1 bottle nitroglycerin 1/150 grain (gr) tablets (used to treat chest pain) with the expiration date of 2/25. 1 bag of lock out tags. The shelf above the sink contained a brown paper bag with unlabeled medication samples that 395109 Page 14 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0761 included: Level of Harm - Minimal harm or potential for actual harm 16 boxes of vrayler (antipsychotic used to treat bipolar disorder (causes extreme mood swings), schizophrenia (affects thinking, behaviors, and feelings), and major depressive disorder (persistent low or depressed mood) 4.5 milligram capsules with 7 capsules per box. Residents Affected - Few 3 boxes of vrayler 6mg capsules with 7 capsules per box. 3 boxes of nuplazid (antipsychotic medication for hallucinations and delusions in Parkinson's disease (movement disorder) psychosis 34 mg capsules 7 capsules per box. During an interview completed on 5/27/25, at 5:55 p.m. Licensed Practical Nurse (LPN) Employee E8 confirmed the above observations and stated the blue tote bag and green back pack belonged to a staff member The green tackle box was to be sent back to the old pharmacy and the brown bag of medications samples were sent with a resident upon return from hospital by the psychiatrist for utilization until insurance authorization was obtained and that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms (back hall medication room). 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 395109 Page 15 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0803 Level of Harm - Minimal harm or potential for actual harm 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. Based on observations, facility menu, resident interviews, and staff interviews it was determined that the facility failed to follow the displayed menu for one of three observed meals on 5/27/25, (Dinner Meal). Residents Affected - Many Findings include: The facility policy Menus reviewed 3/10/25, indicated menus are developed and prepared to meet resident choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy. The dietician reviews and approves all menus. During a dining observation on 5/27/25, at 5:07 p.m. the resident's dinner meals failed to match the approved facility menu for dinner on this date. On 5/27/25, the facility menu was approved by the Registered Dietician (RD) as follow: - Minestrone Soup - Whole wheat crackers - Tuna salad plate - Carrot raisin salad - Mandarin oranges - Coffee, tea, milk On 5/27/25, the facility served residents the following: - Beef vegetable or chicken noodle soup - Whole wheat crackers - Tuna salad plate - 3 bean salad - Mandarin oranges - Coffee, tea, milk During an interview on 5/27/25, at 5:47 p.m. [NAME] Employee E14 stated, We didn't have any Minestrone soup, so I made beef vegetable and chicken noodle soup, and We didn't have any carrot raisin salad, so I served 3 bean salad instead. [NAME] Employee E14 stated, We don't have a lot of stuff on the menu. 395109 Page 16 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 5/27/25, at 6:01 p.m. Dietary Manager Employee E1 stated, The company makes the menus, the RD approves the menus and then we change it around sometimes. I don't get the RD to review the changes and sign off on it. During an interview on 5/27/25, at 6:05 p.m. Dietary Manager Employee E1 confirmed that the facility failed to follow the displayed menu for one of three observed meals on 5/27/25, (Dinner Meal). Pa Code: 211.6(a) Dietary services. 395109 Page 17 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly monitor food expiration dates in the Main Kitchen, failed to maintain food equipment in a clean, sanitary condition, failed to properly restrain beards, failed to maintain sanitary conditions during tray line which created the potential for cross contamination, and failed to verify the sanitizing temperature of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for food borne illness. Findings include: Review of facility policy Date Marking for Food Safety, dated 3/10/25, indicated the facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food the time the food is opened or prepared. The head cook or designee shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly. Review of facility policy Food Preparation and Service, dated 3/10/25, indicated food and nutrition service employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illnesses. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Food and nutrition services staff wear hair restraints (hair net, beard net) so that hair does not contact food. Refrigerated foods are stored in such a way that promotes adequate air circulation around food storage containers. Review of facility policy Dishwasher Temperature, dated 3/10/25, indicated the facility will ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. During an observation on 5/27/25, at 1:15 p.m. in the freezer storage area of the Main Kitchen, the following were observed to be opened and without a date: - Half a bag of bacon pieces, no dates noted During an observation on 5/27/25, at 1:20 p.m. in the walk in cooler area and refrigerator of the Main Kitchen, the following were observed to be opened and without a date or expired: - Ham slices, open date 5/20/25 and expiration date of 5/25/25. - Container of sour cream, opened with no expiration date. - Pineapple salad made 5/19/25 and expiration date of 5/22/25. - Mayonnaise dated 5/18/25 and expiration date of 5/24/25. - Mixed fruit, expiration date of 5/22/25. 395109 Page 18 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0812 Level of Harm - Minimal harm or potential for actual harm During an interview on 5/27/25, at 1:25 p.m. Dietary Manager Employee E1 confirmed the above findings, and confirmed that the facility failed to monitor food expiration dates. During an observation on 5/27/25, at 1:27 p.m. the walk-in cooler fans, ceiling and walls had grim built up on them and the five vents on the ceiling in the main kitchen area had grim built up around them. Residents Affected - Many During an interview on 5/27/25, at 1:45 p.m. Dietary Manager Employee E1 confirmed the above observations and stated, I will get them cleaned right away. During tray line observation on 5/28/25, at 11:45 a.m., [NAME] Employee E3 and [NAME] Employee E4 was noted to have a beard and did not have on a beard net. During an interview on 5/28/25, at 1:45 p.m. Dietary Manager Employee E1 confirmed the above observations and stated, I will get some ordered, we don ' t have any. During tray line observation on 5/28/25, at 11:48 a.m. seven lids that cover resident plates fell off a cart onto the floor. [NAME] Employee E3 picked up the lid covers and proceeded to use them. State Agency surveyor intervened and stopped the staff member from using on resident meals. During an interview on 5/28/25, at 1:45 p.m. Dietary Manager Employee E1 confirmed the above observation. During an observation in the Main Kitchen dish room, on 5/30/25, at 9:30 a.m. it was revealed that the facility does not verify the final rinse temperature of the dish machine by running a temperature test strip through the dish machine to verify the operating condition of the dish machine. During an interview on 5/30/25, at 9:40 a.m. Dietary Manager Employee E1 stated, We don't check the temperature with temperature test strips. I will get a log together and order new strips because I don ' t know how old the current ones are. During an interview on 5/30/25, at 12:02 p.m., Nursing Home Administrator confirmed that the facility failed to properly monitor food expiration dates in the Main Kitchen, failed to maintain food equipment in a clean, sanitary condition, failed to properly restrain beards, failed to maintain sanitary conditions during tray line which created the potential for cross contamination, and failed to verify the sanitizing temperature of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for food borne illness. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management. 395109 Page 19 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (A binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not.) for three of five residents (Resident R12, R33, and R56). Residents Affected - Some Findings include: Review of the facility policy Binding Arbitration Agreements dated 3/10/25, indicated the terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding (i.e. litigation). Review of Resident R12's admission record indicated and admission date of 9/16/24. Review of Resident R12's MDS dated [DATE], indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), hypertension, and depression. Section C0500 BIMS score of five - severe impairment. 1/28/25, signed by Resident R12. Interview with the Nursing Home Administrator on 5/29/25, at 1:32 p.m. indicated Resident R12 did not have the capacity to understand the terms of the Grievance Procedure and Voluntary Arbitration Agreement. Review of Resident R33's admission record indicated and admission date of 4/9/25. Review of Resident R33's MDS dated [DATE], indicated the diagnoses of dementia, hypertension, and depression. Section C0500 BIMS score of five - severe impairment. 3/31/23, signed by Resident R33. Interview with the Nursing Home Administrator on 5/29/25, at 1:34 p.m. indicated Resident R33 did not have the capacity to understand the terms of the Grievance Procedure and Voluntary Arbitration Agreement. Review of Resident R56's admission record indicated and admission date of 5/8/25. Review of Resident R56's MDS dated [DATE], indicated the diagnoses of anemia, hypertension, and stroke (damage to the brain from an interruption of blood supply). Section C0500 BIMS score of eleven moderately impaired. 395109 Page 20 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5/21/25, signed by Resident R56. Interview with the Nursing Home Administrator on 5/29/25, at 1:32 p.m. indicated Resident R56 did not have the capacity to understand the terms of the Grievance Procedure and Voluntary Arbitration Agreement. Interview on 5/29/25, at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement for three of five residents (Resident R12, R33, and R56). 28 Pa Code: 201.18(b)(1)(3)Management. 28 Pa Code: 201.24(a) admission policy. 395109 Page 21 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident clinical records, facility policy, and staff interviews, it was determined the facility failed to obtain a physician order for hospice services and failed to ensure the coordination of hospice services (supportive services for end stage terminal illness) with facility services to meet the needs of each resident for end-of-life care for two of four residents (Resident R22, and R31). Findings include: Review of the facility policy Hospice Program dated 3/10/25, indicated that hospice services are available to residents at the end of life. Upon admission and periodically during their stay, residents are informed of hospice services. The facility collaborates with hospice in care planning process for residents receiving services. Ensures the facility communicates with the resident ' s attending physician. Review of the clinical record revealed that Resident R22 was admitted to the facility on [DATE]. Review of Resident R22's MDS (Minimum Data Set- periodic assessment of resident care needs) dated 5/15/25, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), depression, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section O special treatments: K1. Hospice care, indicated Resident R31 received hospice services while a resident. Review of Resident R22's clinical record failed to reveal a physician order that resident is under hospice services and failed to include a diagnosis related to the need of hospice services. Review of Resident R22's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system, a diagnosis related to the need of hospice services and failed to include the name of the hospice agency being used. Review of the clinical record revealed that Resident R31 was admitted to the facility on [DATE]. Review of Resident R31's MDS dated [DATE], indicated the diagnosis of heart failure (heart doesn't pump blood the way it should), coronary artery disease (CAD- buildup of plaque in the arteries that block blood supply to heart), and anxiety. Section O special treatments: K1. Hospice care, indicated Resident R31 received hospice services while a resident. Review of Resident R31's physician orders revision dated 8/1/24, indicated Resident R31 was admitted to hospice on 6/28/24. Review of Resident R31's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system. During an interview on 5/29/25, at 9:59 a.m. the Director of Nursing (DON) confirmed the facility failed to obtain a physician order for hospice services and failed to ensure the coordination of 395109 Page 22 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0849 hospice services with facility services to meet the needs of each resident for end-of-life care for two of four residents (Resident R22, and R31). Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.14(a) Responsibilities of licensee Residents Affected - Few 28 Pa. Code: 201.18(a)(b)(1)(3) Management 28 Pa. Code: 201.20(a)(b)(d) Staff development 28 Pa. Code: 211.10(c)(d) Resident care policies 395109 Page 23 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on facility policy, clinical record review, observation, and staff interview, it was determined the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for 12 of 12 months (April 2024, - April 2025). Residents Affected - Many Findings include: Review of facility policy Infection Prevention and Control Plan dated 3/10/25, indicated an infection prevention and control program is established to maintain and provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveillance tools are used for identifying the occurrence of infections, recording their numbers and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. Review of the facility's monthly tracking of surveillance on 5/28/25, failed to include floor mapping for twelve of twelve months April 2024, - April 2025. Interview on 5/28/25, at 12:09 p.m. Infection Preventionist Employee E13 confirmed the facility failed to implement an effective infection control plan as required for the months of April 2024, - April 2025 and was unable to produce the documents with surveillance including floor mapping. 28 Pa. code: 201.14 Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.10(a)(d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services. 395109 Page 24 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of two crash carts (Front and Back hallways). Residents Affected - Some Findings include: Review of facility policy Emergency Crash Cart and Automated External Defibrillators (AED's) dated [DATE], indicated it is the policy of the facility to ensure that the facility will maintain at least one emergency cart per nursing care floor in case of the need for basic life support. To ensure that all supplies critical to basic life support are readily available on the emergency cart. The emergency crash cart is checked every 24-hours and after every use. Missing or expired items are replaced, when applicable. During an observation of the Back hallway crash cart (a cart maintained with equipment used in cardiac emergencies) on [DATE], at 2:15 p.m. revealed a binder Crash Cart Checklist. Review of the binder failed to include a checklist for [DATE]. Interview on [DATE], at 2:15 p.m. Licensed Practical Nurse (LPN) Employee E8 verified the binder did not have a check list initiated for the current month of [DATE]. During an observation of the Front hallway/Dining room crash cart on [DATE], at 2:20 p.m. revealed a binder Crash Cart Checklist. Review of the binder indicated that 14 days failed to include documentation that the cart was checked for emergency readiness as required. The following dates failed to include documentation: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Interview on [DATE], at 2:20 p.m. Registered Nurse (RN) Employee E9 verified the Crash Cart Checklist failed to include documentation on 14 days. During an interview on [DATE], at 2:35 p.m. the Director of Nursing confirmed that the facility failed to make certain that equipment was in safe operating condition for two of two crash carts (Front and Back hallways). 28 Pa Code: 201.14(a) Responsibility of licensee. 395109 Page 25 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on facility policy, pest control log, observations, and staff interviews it was determined the facility failed to maintain an effective pest control program related to gnats in the kitchen (Main Kitchen). Residents Affected - Many Findings include: Review of the facility Pest Control policy dated 3/10/25, indicated that the facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During a kitchen tour on 5/27/25, at 1:00 p.m. an observation of the storage room where dry foods are stored had an abundance number of gnats on the boxes/cans of goods or were flying around in the area. During an observation on 5/27/25, at 1:10 p.m. gnats were observed flying around the main kitchen area above the prep table and around the dish machine. During an observation on 5/27/25, at 1:30 p.m. mounted bug lights were observed hanging on the wall by the door and in the back storage area where the ice machine is kept. During an interview on 5/27/25, at 1:33 p.m. Dietary Manager Employee E1 stated, I've been here for three months and have been trying to fix the gnat problem, and confirmed the above observations. During an observation on 5/28/25, at 11:30 a.m. gnats were flying throughout the kitchen while staff were working. An observation of approximately 40 gnats on the wall beside the microwave were observed. During an interview on 5/28/25, at 11:45 a.m. [NAME] Employee E3 stated, These gnats are terrible. They are everywhere. During an interview on 5/28/25, at 11:50 a.m. [NAME] Employee E4 stated We had a problem with water damage and parts of the ceiling came down last year. I don't think it is fixed properly. The gnats are coming from the moisture, and they have been here for a while. Review of facility provided documentation included pest-control log dated 5/6/25. Inspection report indicated: - Fungus gnats observed in dry food storage (live) - Fungus gnats observed in kitchen (live) - Certain service areas not available for inspection/treatment: Please arrange to have the identified are accessible for inspection or treatment on the next service visit. - Actions Taken: Fungus gnats. Inspected and previous conditions still exist. - Findings: Repair or dry out walls or wood that has been damaged by water 395109 Page 26 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0925 During an interview on 5/28/25, at 1:45 p.m. Dietary Manager confirmed that the facility failed to maintain an effective pest control program related to gnats in the kitchen (Main Kitchen). Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14(a) Responsibility of licensee Residents Affected - Many 28 Pa. Code 201.18(b)(3) Management 395109 Page 27 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0941 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on effective communication for two of five staff members (Nurse Aide (NA) Employees NA E11, and NA E12). Findings include: Review of the policy In-service Training, Nurse Aide dated 3/10/25, indicated all personnel are required to participate in regular in-service education. Required training topics for all staff (including Nurse aides) include communication, resident rights and facility responsibilities, abuse, neglect and exploitation of residents, quality assurance and performance improvement (QAPI), infection control, compliance and ethics, and behavioral health. Review of facility provided documents and training records for NA Employees E11 and NA Employee E12, revealed the following staff members did not have documented training on effective communication. NA Employee E11 had a hire date of 8/27/1989, failed to have effective communication in-service education between 2/8/24, and 2/8/25. NA Employee E12 had a hire date of 8/19/21, failed to have effective communication in-service education between 2/8/24, and 2/8/25. Interview on 5/30/25, at approximately 11:30 a.m. the Director of Nursing confirmed that the facility failed to provide training on effective communication for two of five staff members (Nurse Aide (NA) Employees NA E11, and NA E12). 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(6)(d) Staff development. 395109 Page 28 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for four of five employees (Nurse Aide (NA) Employees E10, E11, E12, and Licensed Practical Nurse (LPN) Employee E8). Findings include: Review of the Facility Assessment dated 3/10/25, indicated staff training/education and competencies will be completed during general orientation upon hire, annually, and as needed. Educations listed included: -Communication, resident rights and facility responsibilities, abuse, neglect and exploitation of residents, quality assurance and performance improvement (QAPI), infection control, compliance and ethics, and behavioral health. NA Employee E10 had a hire date of 4/11/18, failed to have QAPI in-service education between 3/15/24, and 3/15/25. NA Employee E11 had a hire date of 8/27/1989, failed to have QAPI in-service education between 2/8/24, and 2/8/25. NA Employee E12 had a hire date of 8/19/21, failed to have QAPI in-service education between 2/8/24, and 2/8/25. LPN Employee E8 had a hire date of 6/7/06, failed to have QAPI in-service education between 2/6/24, and 2/6/25. Interview on 5/30/25, at approximately 11:30 a.m. the Director of Nursing confirmed that the facility failed to provide training on QAPI for four of five employees (Nurse Aide (NA) Employees E10, E11, E12, and Licensed Practical Nurse (LPN) Employee E8). 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(6)(d) Staff development. 395109 Page 29 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0946 Provide training in compliance and ethics. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide compliance and ethics training for four of five staff members (Nurse Aide (NA) Employees E10, E11, E12, and Licensed Practical Nurse (LPN) Employee E8). Residents Affected - Some Findings include: Review of the Facility Assessment dated 3/10/25, indicated facility staff will complete annual mandatory training on compliance and ethics. Review of the policy In-service Training, Nurse Aide dated 3/10/25, indicated all personnel are required to participate in regular in-service education. Required training topics for all staff (including Nurse aides) include: Communication, resident rights and facility responsibilities, abuse, neglect and exploitation of residents, quality assurance and performance improvement (QAPI), infection control, compliance and ethics, and behavioral health. NA Employee E10 had a hire date of 4/11/18, failed to have compliance and ethics in-service education between 3/15/24, and 3/15/25. NA Employee E11 had a hire date of 8/27/1989, failed to have compliance and ethics in-service education between 2/8/24, and 2/8/25. NA Employee E12 had a hire date of 8/19/21, failed to have compliance and ethics in-service education between 2/8/24, and 2/8/25. LPN Employee E8 had a hire date of 6/7/06, failed to have compliance and ethics in-service education between 2/6/24, and 2/6/25. Interview on 5/30/25, at approximately 11:30 a.m. the Director of Nursing confirmed that the facility failed to provide training on compliance and ethics for four of five employees (Nurse Aide (NA) Employees E10, E11, E12, and Licensed Practical Nurse (LPN) Employee E8). 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(6)(d) Staff development. 395109 Page 30 of 31 395109 05/30/2025 Beaver Healthcare and Rehabilitation Center 616 Golf Course Road Aliquippa, PA 15001

F 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide behavioral health training as determined by the Facility Assessment for two of five staff members (Employees E8, and E10). Findings include: Review of the Facility Assessment dated 3/10/25, indicated facility staff will complete annual mandatory training on behavioral health. Licensed Practical Nurse (LPN) Employee E8 had a hire date of 6/7/06, failed to have behavioral health in-service education between 2/6/24, and 2/6/25. Nurse Aide (NA) Employee E10 had a hire date of 4/11/18, failed to have behavioral health in-service education between 3/15/24, and 3/15/25. Interview on 5/30/25, at approximately 11:30 a.m. the Director of Nursing confirmed that the facility failed to provide training on behavioral health for two of five employees (Employees E8, and E10). 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(6)(d) Staff development. 395109 Page 31 of 31

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Citations

19 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0600GeneralS&S Dpotential for harm
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
0605GeneralS&S Dpotential for harm
F605 - Respect and Dignity
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
0607GeneralS&S Dpotential for harm
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
0620GeneralS&S Epotential for harm
F620 - Admissions policy
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0730GeneralS&S Epotential for harm
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0849GeneralS&S Dpotential for harm
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0908GeneralS&S Epotential for harm
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
0925GeneralS&S Fpotential for harm
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
0941GeneralS&S Dpotential for harm
F941 - Training Requirements
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
0944GeneralS&S Epotential for harm
F944 - Quality assurance and performance improvement
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
0946GeneralS&S Epotential for harm
F946 - Compliance and ethics
Provide training in compliance and ethics.
0949GeneralS&S Dpotential for harm
F949 - Training Requirements
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
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.
0803GeneralS&S Fpotential for harm
F803 - Menus and nutritional adequacy
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.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0847GeneralS&S Epotential for harm
F847 - Entering Into Binding Arbitration Agreements
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

FAQ · About this visit

Common questions about this visit

What happened during the May 30, 2025 survey of BEAVER HEALTHCARE AND REHABILITATION CENTER?

This was a inspection survey of BEAVER HEALTHCARE AND REHABILITATION CENTER on May 30, 2025. The surveyor cited 19 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BEAVER HEALTHCARE AND REHABILITATION CENTER on May 30, 2025?

Yes, 19 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed July 27, 2026. If you believe any information is inaccurate, report it here.

Health inspection·May 30, 2025