Beaver Valley Rehabilitation and Healthcare Center

Inspectors wroteBased on review of facility policy, clinical records and staff interviews it was determined that the facility failed to provide assistance with Activities of Daily Living (ADL) involving consistent shower or baths for two out of six residents (Resident R2 and Resident R3).

Inspectors wroteBased on review of facility policy review, resident clinical records, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for three of five sampled residents (Residents R1, R4 and Resident R5).

Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to conduct surveillance mapping for five of 12 months (October 2024, February 2025, April 2025, August 2025, and September 2025), failed to timely implement isolation precautions during contact tracing testing for candida auris, failed to implement universal masking and droplet precautions throughout the facility timely for one of five residents (Residents R116), report newly identified cases within 24 hours during a COVID outbreak for four residents (Resident R50, R51, R54, and R91) and two staff members (Nurse Aide, Employee E16 and NA, Employee E24)and failed to prevent cross contamination during a medication pass for one of three resident's (Resident R91).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to discontinue a physician order for one of one resident (Resident R2), failed to provide appropriate care and services for a resident with a wound vac (Resident R16), failed to discontinue skin treatments (Resident R32), failed to obtain physician orders to provide parameters of when to notify the physician of increased/decreased Capillary Glucose levels (CBG) for one of three residents (Resident R89).

Inspectors wroteBased on review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for five out of five nurse aides (NA Employee E1, E2, E3, E4, E5).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide evidence medication regimen reviews (MRR) were reviewed by the resident's attending physician monthly for four of six residents (Resident R6, R10, R11, R59).

Inspectors wroteBased 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 in one of two medication rooms (first floor medication room) and three of five medications carts (second floor South Hall, first floor South Hall and first floor [NAME] Hall).

Inspectors wroteBased on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of six residents (Residents R16).

Inspectors wroteBased on review of clinical records and resident and staff interviews, it was determined that the facility failed to the notify resident representative and/or medical provider of a change in condition/status for one of three residents (Resident R66).

Inspectors wroteBased on facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF-ABN) for one of three sampled resident records (Closed Resident Record CR132).

Inspectors wroteBased on review of facility policies, clinical records, facility documents, and staff interviews it was determined that the facility failed to identify a seat belt and table attached to a wheelchair and leg straps placed over a residents thighs as a possible restraint, and failed to assess the functional status of the individual residents to determine if the use of a seatbelt or table attached to a wheelchair and leg straps placed over a residents thighs is a restraint for two of four residents (Residents R15 and R58).

Inspectors wroteBased on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that each resident's drug regimen was free from unnecessary psychotropic drugs used without adequate indications for use for one of three residents (Resident R98).

Inspectors wroteBased on review of facility documentation, review of clinical records and staff interview it was determined that the facility failed to ensure an appropriate discharge for one of three residents and failed to notify the ombudsman of the correct living arrangement for one of three residents (Closed Record Resident R131).

Inspectors wroteBased on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for one of four residents (Resident R8).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop a baseline care plan for one of three residents (Resident R4).

Inspectors wroteBased on facility policy, review of clinical record, observation, and resident and staff interview, it was determined that the facility failed to provide appropriate foot care to one of six residents (Residents R15).

Inspectors wroteBased on review of facility policies and documents, clinical records, and staff interviews, it was determined that the facility failed to provide prescribed treatment and services related to the care of a PICC line (peripherally inserted central catheter, a long, thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) for two of two residents (Resident R16 and R42). Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/2/25, indicated diagnoses of high blood pressure, diabetes (high sugar in the blood) and encounter for orthopedic aftercare following surgical amputation. [...]

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of two residents (Residents R89) and ensured fluid restrictions were maintained for one of two residents (Resident R89).

Inspectors wroteBased on review of resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R1).

Inspectors wroteBased on review of facility documentation, clinical record and staff interview it was determined that the facility failed to provide medically related social services for one of three residents reviewed (Closed Record Resident R131).

Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for two of five residents reviewed (Residents R89 and R91).

Inspectors wroteBased on facility policy review, review of the Quality Assurance attendance records, and staff interview it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required members for one of three quarters (Quarter one of 2025).

Inspectors wroteBased on review of facility policy, closed resident clinical records, facility documents, staff interviews, it was determined that the facility failed to report an allegation of sexual abuse for one of five sampled residents (Closed Resident Record CR1).

Inspectors wroteBased on review of facility policy, closed clinical records and staff interviews, it was determined that the facility failed to make certain allegations of abuse are thoroughly investigated for one of five sampled residents (Closed Resident Record CR1).

Inspectors wroteBased on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of three residents (Residents R96).

Inspectors wroteBased on review of facility policies, resident records and staff interview, the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two out of two residents sampled with facility-initiated transfers (Resident R21 and R60).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer for two of two residents (Residents R21 and R60).

Inspectors wroteBased on review of facility policy, resident observations, clinical record review and staff interviews, it was determined that the facility failed to develop a plan of care to include a focus and interventions to maintain a resident's highest practicable physical well-being as required for one of three residents. (Resident R28)

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident had a physician order for treatment residents were receiving for two of five residents (Resident R28 and 260).

Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to make certain that appropriate treatment and services were ordered and/or provided for two of three residents with a urinary catheter (Resident R37 and R260).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for one of three residents reviewed (Resident R51).

Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R36, and R84).

Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing assessments to ensure that bed rails were used to meet residents' needs and the risks associated with bed rail usage for two of five residents (Residents R51 and R79).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly and securely in one of three medications carts (one [NAME] medication cart).

Inspectors wroteBased on review of facility policy, resident clinical records, observation, and staff interviews, it was determined that the facility failed to implement infection control monitoring and management during a COVID-19 outbreak for one out of two residents (Resident R6) and failed to prevent cross contamination during a dressing change for one of three residents (Resident R13).

Inspectors wroteBased on review of resident clinical records, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of three residents (Resident R1, and R9). Findings Include: A review of the facility policy Transfer and discharge- 30 day last reviewed 7/9/24, indicated a resident/representative will be notified in writing the reason for the transfer or discharge using the notice of transfer or discharge form, this includes sending a copy to the Office of the Long-Term Care Ombudsman A review of Resident R1's clinical record indicates admission date of 7/12/24, with the diagnoses of Vascular Dementia with agitation (decline in thinking skills caused by reduced blood flow), Urinary tract infection (infection in the urinary system), and Hypertension (high blood pressure). [...]

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to permit the readmission of a hospitalized resident without providing evidence that the facility was not able to meet the resident's needs for one of three residents reviewed (Resident R1). A review of the facility policy Transfer and discharge- 30 day last reviewed 7/9/24, indicated a resident and/or his or her representative (sponsor), will be given a thirty-day advanced notice of an impending transfer or discharge from facility. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge. The transfer is necessary for the resident ' s welfare and the resident ' s needs cannot be met in the facility. [...]

Inspectors wroteBased on review of facility policy and resident interviews and observations, it was determined that the facility failed to ensure sufficient staffing to meet resident need for eight of twelve residents (Resident R1, R2, R3, R4, R5, R6, R7, and R8).

Inspectors wroteBased on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility (Main Kitchen).

Inspectors wroteBased on review of facility policy, a resident council group interview, observations and staff interview it was determined that the facility failed to maintain proper ventilation for two out of two Resident Central Shower Rooms (First and Second Floors).

Inspectors wroteBased on observations, review of federal regulations, facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for four of four residents (Residents R4, R13, R20, and R69).

Inspectors wroteBased 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 five nurse aide personnel records (Nurse aides (NA) Employee E2, NA Employee E3, and NA Employee E4).

Inspectors wroteBased on review of facility policy and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of four dialysis residents. (Resident R58 and R61).

Inspectors wroteBased on review of facility policy, observations and staff interview it was determined that the facility failed to date opened medications and properly store medications in one of three medication carts observed (North Hall second floor cart).