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Deficiency Records for Beaver Healthcare and Rehabilitation Center
A list of the most recent deficiencies for Beaver Healthcare and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Beaver Healthcare and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-09-04 | 2024-09-30 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-09-04 | 2024-09-30 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-09-04 | 2024-09-30 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-08-08 | 2024-08-23 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-06-06 | 2024-07-01 | Y |
| 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. | Health | 2024-06-06 | 2024-07-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-05 | 2024-04-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-05 | 2024-04-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-05 | 2024-04-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-05 | 2024-04-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-05 | 2024-04-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-05 | 2024-04-19 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-03-05 | 2024-04-19 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-03-05 | 2024-04-19 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-03-05 | 2024-04-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-03-05 | 2024-04-19 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-03-05 | 2024-04-19 | N |
| 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. | Health | 2024-03-05 | 2024-04-19 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-03-05 | 2024-04-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-05 | 2024-04-19 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-03-05 | 2024-04-19 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-03-05 | 2024-04-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-05 | 2024-04-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-03-05 | 2024-04-19 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-03-05 | 2024-04-19 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-03-05 | 2024-04-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-05 | 2024-04-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-05 | 2024-04-19 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-03-05 | 2024-04-19 | Y |
| 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. | Health | 2024-03-05 | 2024-04-19 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2024-03-05 | 2024-04-19 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-07 | 2024-03-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-26 | 2024-02-20 | Y |
| 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. | Health | 2023-10-18 | 2023-11-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-17 | 2023-08-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-17 | 2023-08-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-17 | 2023-08-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-07-17 | 2023-08-08 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-06-09 | 2023-07-24 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-06-09 | 2023-07-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-09 | 2023-07-24 | N |
| Respond appropriately to all alleged violations. | Health | 2023-06-09 | 2023-07-24 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-06-09 | 2023-07-24 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-06-09 | 2023-07-24 | N |
| 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. | Health | 2023-06-09 | 2023-07-24 | N |
| 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. | Health | 2023-06-09 | 2023-07-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-09 | 2023-07-24 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-06-09 | 2023-07-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-09 | 2023-07-24 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-06-12 | 2023-07-24 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-06-12 | 2023-07-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-12 | 2023-07-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-12 | 2023-07-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-12 | 2023-07-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-12 | 2023-07-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-03-22 | 2023-05-02 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-03-22 | 2023-05-02 | Y |
| 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. | Health | 2023-03-22 | 2023-05-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-22 | 2023-05-02 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-03-10 | 2023-04-04 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-01-10 | 2023-02-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-10 | 2023-02-07 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-11-21 | 2023-01-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-21 | 2023-01-05 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-11-21 | 2023-01-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-21 | 2023-01-05 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-11-21 | 2023-01-05 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-11-21 | 2023-01-05 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-11-21 | 2023-01-05 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-08-08 | 2022-09-27 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-08-08 | 2022-09-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-08 | 2022-09-27 | N |
| Respond appropriately to all alleged violations. | Health | 2022-08-08 | 2022-09-27 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-08-08 | 2022-09-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-08 | 2022-09-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-08 | 2022-09-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-08 | 2022-09-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-08 | 2022-09-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-08 | 2022-09-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-08-08 | 2022-09-27 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-08 | 2022-09-27 | N |
| 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. | Health | 2022-08-08 | 2022-09-27 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-08-08 | 2022-09-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-08 | 2022-09-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-08 | 2022-09-27 | N |
| 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. | Health | 2022-08-08 | 2022-09-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-08 | 2022-09-27 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-08-08 | 2022-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-08 | 2022-09-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-08-08 | 2022-09-27 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-08 | 2022-09-27 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-08-08 | 2022-09-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-08 | 2022-09-27 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-08-08 | 2022-09-27 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-08 | 2022-09-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-08 | 2022-09-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-19 | 2022-05-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-14 | 2022-01-07 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-11-02 | 2021-11-08 | Y |
| 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. | Health | 2021-11-02 | 2021-11-08 | Y |
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