Beaver County Nursing Home

In the surveyor’s words

From the most serious findings on record at Beaver County Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 12, 2024

  An IJ was identified from 12/11/24 through 12/12/24. The deficient practice remained at isolated level of a potential for harm. On 12/11/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement fall interventions for a resident with severe cognitive impairment and high fall risk. On 12/10/24, Resident #13 had a fall with injury in their room. Resident #13 fell during an independent transfer and was found by staff on the floor with their left foot rotated outward with no range of motion to left hip. Resident #13 was taken to the ER by staff. […]

• No harm, potential for more than minimal, widespreadF812Jul 21, 2022

  Based on record review, observation, and interview the facility failed to: a. ensure temperatures were obtained and foods were held at 135 degrees on the holding table, and b. ensure dishes and utensils were cleaned/sanitized to prevent food borne illness. The Administrator identified 40 residents who received their meals from the kitchen. Findings: A policy titled, Food Temperatures, review date [DATE], read in part, . Ensure food is served at a safe temperature to prevent food-borne illness .Hot Foods should be maintained at a minimum of 135 degrees F . […]

• No harm, potential for more than minimal, patternF656Dec 12, 2024

  Based on record review and interview, the facility failed to ensure fall interventions were individualized and revised after a fall for residents assessed as a high risk for falls for two (#13 and #15) of two sampled residents reviewed for individualized care plans. The administrator identified 35 residents resided in the facility Findings: An undated facility Accidents policy, read in part, The intent of this policy is to ensure this facility provides an environment that is free from accidents hazards over which the facility has control and provides supervision and assistive devices are provided for each resident to prevent avoidable accidents. This includes: a. Identifying hazards and risk, b. Evaluating and analyzing hazards and risk, c. […]

• No harm, potential for more than minimal, patternF727Dec 12, 2024

  Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours, seven days per week. The administrator identified 35 residents resided in the facility. Findings: A PBJ Staffing Report, dated 07/01/24 through 09/30/24, did not document any RN hours for 07/06/24, 07/07/24, 07/12/24, and 07/13/24. A Nurses Schedule, dated July 2024, were reviewed and schedule did not document RN coverage for 07/06/24, 07/07/24, 07/13/24, and 07/14/24. On 12/11/24 at 11:03 a.m., the administrator was asked what the facility policy for staffing an RN eight hours a day seven days a week. They stated the facility should have RN coverage eight hours a day, seven days a week. […]

• No harm, potential for more than minimal, patternF759Dec 12, 2024

  Based on observation, record review, and interview, the facility failed to ensure a medication rate of less than 5%. A total of 25 opportunities were observed during the medication pass with two errors identified. The total medication error rate was 8% related to two medications held without physician orders for parameters to hold medications for one (#11) of three sampled residents observed during medication pass. The administrator identified 35 residents resided in the facility. […]