Friendship Rehab And Health

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

under chair, patient was tied down by bed sheet, knotted under chair. Myself and NA Employee E2 untied and repositioned patient while our therapy secretary (Therapy Assistant Employee E3) braced the wheelchair for us. Therapy Assistant Employee E3 stated, Walking floor for therapy appointments and stopped to help PT Employee E1 and NA Employee E2 by bracing back of cardiac chair belonging to Resident Resident R1. After multiple unsuccessful attempts at repositioning, NA Employee E2 looked under chair to find patient tied down by bed sheet - knotted tightly under chair. Resident Resident R1 was tied around her midsection (over ribcage) and was immobile. NA Employee E2 untied knot and NA Employee E2 and PT Employee E1 were able to reposition Resident Resident R1. Resident Resident R1 seemed unaware of her predicament but nonetheless was checked for further physical/emotional harm. NA Employee E2 stated, We went to go move Resident Resident R1 up in the chair and it seemed as if she was stuck, so we checked around the chair. we ended up finding out that the flat sheet was tied around her belly and under the chair in a knot. During an

interview on 8/27/25, at 11:05 a.m. the Director of Nursing (DON) confirmed that the facility failed to ensure Resident Resident R1 was free from abuse. This was identified for past non-compliance for Resident Resident R1. During this interview, the DON confirmed the facility was able to identify an AP and the employee had been terminated from the facility. The facility implemented a plan of correction that included the following:Resident Resident R1 was assessed and no injury was identified, no signs or symptoms of pain or discomfort.Walking rounds were completed on all units 8/19/25, no additional restraints in use.Facility abuse policy was reviewed with no revisions made.DON implemented re-education in all departments on abuse prevention policy; staff to be educated prior to next shift.On 8/20/25 the MDS Coordinator reviewed all active care plans to ensure use of restraints was not care planned for any residents. No issues were identified.As of 8/21/24, facility was >90% with regard to abuse education.Beginning on 8/21/25, DON or designee will begin auditing cognitively impaired residents on 5 units daily for 1 week, then 3 units daily for 1 week, then 2 units daily for 2 weeks to ensure cognitively impaired residents are free from physical restraints. Review of facility documentation included the followingEducation for all employees on abuse prevention policy, including under no circumstances are residents to be restrained in a way that prevents them from moving independently.8/19/25, walking rounds completed on all units to ensure no residents had any type of restraints in use. No restraints present.8/20/25, all active care plans reviewed. Confirmed there are no interventions encouraging the use of restraints.Ad-hoc meeting of QAPI (Quality Assurance and Performance Improvement) completed 8/19/25.Ongoing audits for restraint use completed 8/21/25, 8/22/25, 8/23/25,8/24/25, 8/25/25, and 8/26/25. During interviews on 8/27/25, fifteen staff to include nurses, nurse aides, and therapy staff verified they were trained on the facility abuse prevention policy and restraints. The facility has demonstrated compliance with the above since 8/22/25. Information was reviewed via Plan of Correction documentation. During an interview on 8/27/25, at 2:56 p.m. with the DON and review of facility's immediate actions, education, and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are free from abuse. 28 Pa. Code: 201.14(a) Responsibility of licensee28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brighton Rehabilitation and Wellness Center

246 Friendship Circle Beaver, PA 15009

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

physical/emotional harm. NA Employee E2 stated, We went to go move Resident Resident R1 up in the chair and it seemed as if she was stuck, so we checked around the chair. we ended up finding out that the flat sheet was tied around her belly and under the chair in a knot. During an interview on 8/27/25, at 11:05 a.m. the Director of Nursing (DON) confirmed that the facility failed to ensure Resident Resident R1 was free from physical restraints. This was identified for past non-compliance for Resident Resident R1. During this interview, the DON confirmed the facility was able to identify an AP and the employee had been terminated from the facility.

The facility implemented a plan of correction that included the following: Resident Resident R1 was assessed and no injury was identified, no signs or symptoms of pain or discomfort.Walking rounds were completed on all units 8/19/25, no additional restraints in use.Facility abuse policy was reviewed with no revisions made.DON implemented re-education in all departments on abuse prevention policy; staff to be educated prior to next shift.On 8/20/25 the MDS Coordinator reviewed all active care plans to ensure use of restraints was not care planned for any residents. No issues were identified.As of 8/21/24, facility was >90% with regard to abuse education.Beginning on 8/21/25, DON or designee will begin auditing cognitively impaired residents on 5 units daily for 1 week, then 3 units daily for 1 week, then 2 units daily for 2 weeks to ensure cognitively impaired residents are free from physical restraints. Review of facility documentation included

the following: Education for all employees on abuse prevention policy, including under no circumstances are residents to be restrained in a way that prevents them from moving independently.8/19/25, walking rounds completed on all units to ensure no residents had any type of restraints in use. No restraints present.8/20/25, all active care plans reviewed. Confirmed there are no interventions encouraging the use of restraints.Ad-hoc meeting of QAPI (Quality Assurance and Performance Improvement) completed 8/19/25.Ongoing audits for restraint use completed 8/21/25, 8/22/25, 8/23/25,8/24/25, 8/25/25, and 8/26/25.

During interviews on 8/27/25, fifteen staff to include nurses, nurse aides, and therapy staff were trained on

the facility abuse prevention policy and restraints. The facility has demonstrated compliance with the above since 8/22/25. Information was reviewed via Plan of Correction documentation. During an interview on 8/27/25, at 2:56 p.m. with the DON and review of facility's immediate actions, education, and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are free from abuse. 28 Pa. Code: 201.14(a) Responsibility of licensee28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Event ID:

Facility ID:

If continuation sheet