Friendship Rehab And Health
Friendship Rehab and Health in BEAVER, PA — inspection on August 27, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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 R1 was free from abuse.
This was identified for past non-compliance for 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 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/27/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Brighton Rehabilitation and Wellness Center
246 Friendship Circle Beaver, PA 15009
SUMMARY STATEMENT OF DEFICIENCIES
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 R1 was free from physical restraints.
This was identified for past non-compliance for 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 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.
Facility ID: