Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beaver County Nursing Home during CMS and state inspections, most recent first.
An IJ situation was identified due to a facility's failure to implement individualized fall interventions for residents with high fall risk. One resident with severe cognitive impairment suffered a significant injury from a fall, and another resident with dementia experienced multiple falls without updates to their care plan. The facility used generic interventions rather than tailoring plans to individual needs, contributing to ongoing fall risks.
Two residents at a facility experienced multiple falls without their care plans being updated with individualized interventions, despite being assessed as high fall risks. The facility's policy required person-centered interventions, but the care plans remained generic and unchanged after the incidents. The MDS coordinator and administrator confirmed the lack of specific interventions tailored to the residents' needs.
The facility did not maintain RN coverage for eight consecutive hours, seven days a week, as required. The administrator confirmed the absence of RN coverage on specific days in July, as indicated by the PBJ Staffing Report and Nurses Schedule. The facility had 35 residents during this period.
A facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during a medication pass. A resident's medications, quinapril and Lasix, were held without physician orders due to a low blood pressure reading. The CMA and DON lacked clarity on the parameters for holding these medications, contributing to the errors.
The facility failed to ensure proper hand hygiene during meal assistance, as the DON was observed assisting multiple residents without washing or sanitizing hands between them. The residents involved had significant cognitive impairments and required varying levels of assistance with eating. The infection preventionist confirmed the observation, and the DON acknowledged the oversight.
A resident with legal blindness and anxiety disorder exhibited inappropriate behavior by urinating on the dining room floor. The facility failed to notify the resident's family and physician, as confirmed by interviews with staff and the resident's POA. The incident was not documented in the EHR, and the facility lacked a policy for such notifications.
A facility failed to follow its policy for changing oxygen (O2) tubing, leading to a deficiency. A resident with chronic conditions had O2 tubing dated over a month old, contrary to the policy requiring changes every seven days. Staff interviews revealed inconsistencies in understanding the policy, with an LPN stating monthly changes and the DON indicating bimonthly changes, while the administrator confirmed monthly changes.
A resident with hypertension, edema, and dementia did not receive prescribed quinapril and Lasix due to a CMA holding the medications based on low blood pressure, despite no physician's orders to do so. The DON confirmed the absence of parameters for withholding these medications, highlighting a failure to follow the facility's medication error policy.
Failure to Implement Individualized Fall Interventions
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified in a facility due to the failure to implement fall interventions for a resident with severe cognitive impairment and a high risk of falling. The deficiency was noted when a resident, who had a history of falls, experienced a fall resulting in a significant injury. The resident was found on the floor with a rotated left foot and no range of motion in the left hip, leading to a diagnosis of a closed displaced intertrochanteric fracture of the left femur and a scalp laceration. Despite previous falls, the care plan for this resident was not updated with new specific interventions to prevent further incidents. The facility's failure to update and implement individualized fall interventions was also evident in another resident's case. This resident, admitted with dementia and anxiety, had multiple falls without subsequent updates to their care plan. The care plan contained generic interventions that were not tailored to the resident's specific needs, and no new interventions were added after the falls. The facility's protocol involved using a list of interventions for all residents who fall, rather than creating individualized plans. Interviews with facility staff, including the MDS coordinator and the administrator, confirmed that the care plans were not individualized and specific to the residents. The staff acknowledged that no new interventions were added after the falls, and the interventions in place were part of a generic list applied to all residents. This lack of individualized care planning contributed to the continued risk of falls and injuries for residents assessed as high fall risks.
Failure to Individualize and Update Fall Interventions
Penalty
Summary
The facility failed to ensure that fall interventions were individualized and revised after falls for two residents who were assessed as high risk for falls. The facility's policy required that individualized, person-centered interventions be implemented to reduce risk related to hazards in the environment. However, the care plans for both residents did not reflect any new specific interventions after multiple falls occurred. Resident #13, who had diagnoses including heart failure, weakness, dizziness, cataract, and anxiety, experienced several falls without subsequent updates to their care plan. Despite being identified as a high fall risk with a score of 75, and having a severely impaired cognition, the care plan remained unchanged after falls on 08/01/24, 11/29/24, and 12/10/24. The MDS coordinator confirmed that no new interventions were put into place following these incidents, and the interventions listed were generic rather than tailored to the resident's specific needs. Similarly, Resident #15, who was admitted with unspecified dementia and anxiety, also experienced falls without updates to their care plan. Despite being assessed as a high risk for falling, the care plan did not document any new interventions after falls on 02/08/24 and 04/27/24. The MDS coordinator acknowledged that the interventions were not specific to the resident but were part of a standard list applied to all residents who had falls. The administrator confirmed that the care plan was not individualized and specific to the resident, indicating a failure to adhere to the facility's policy for individualized care planning.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours, seven days per week, as required. The administrator confirmed that the facility's policy mandates RN coverage for this duration. However, a review of the PBJ Staffing Report from 07/01/24 through 09/30/24 revealed no documented RN hours on 07/06/24, 07/07/24, 07/12/24, and 07/13/24. Additionally, the Nurses Schedule for July 2024 did not document RN coverage for 07/06/24, 07/07/24, 07/13/24, and 07/14/24. Upon inquiry, the administrator acknowledged the absence of RN coverage on these specific days. The facility housed 35 residents at the time of the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by an 8% error rate observed during a medication pass. During the observation, 25 medication opportunities were reviewed, and two errors were identified. Specifically, a resident with diagnoses of hypertension, edema, and dementia had their medications, quinapril and Lasix, held without physician orders specifying parameters for holding these medications. The Certified Medication Aide (CMA) held the medications due to a blood pressure reading of 96/59, but there were no documented orders to support this action. The Director of Nursing (DON) was uncertain about the parameters for holding a diuretic medication like Lasix, indicating a lack of clarity in medication administration protocols.
Failure to Follow Hand Hygiene Protocol During Meal Assistance
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during meal assistance, as observed during a dining session. The Director of Nursing (DON) was seen assisting multiple residents with feeding without washing or sanitizing their hands between residents. Specifically, the DON assisted three residents with eating, moving from one resident to another without performing hand hygiene, which is a violation of the facility's Handwashing/Hand Hygiene policy. This policy requires handwashing or the use of an alcohol-based hand rub before and after assisting a resident with meals. The residents involved in the observed deficiency included individuals with significant cognitive impairments and varying levels of dependency for eating assistance. One resident had unspecified dementia and delusional disorder, another had Alzheimer's disease and metabolic encephalopathy, and the third was legally blind with an adjustment disorder and anxiety. The infection preventionist confirmed witnessing the lack of hand hygiene and was unsure of the policy details, while the DON acknowledged the failure to sanitize between residents during the meal assistance.
Failure to Notify Family and Physician of Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to notify a resident's physician and family representative of inappropriate behaviors exhibited by the resident. The resident, who was admitted with diagnoses including legal blindness, adjustment disorder with depression, and anxiety disorder, was reported to have stood up, pulled down their pants, and urinated on the floor in the dining room. This incident was observed by a CNA and documented in a progress note. However, the resident's Power of Attorney (POA) confirmed that they were not informed of the incident. Interviews with facility staff, including an LPN, the DON, and the administrator, revealed that there was no documentation in the Electronic Health Record (EHR) indicating that the family or physician was notified of the behavior. The DON and administrator acknowledged the lack of notification and documentation, and it was noted that the facility did not have a policy regarding notifications for such incidents. The failure to notify relevant parties was identified as a deficiency in the facility's procedures.
Failure to Change Oxygen Tubing as Per Policy
Penalty
Summary
The facility failed to adhere to its policy for changing oxygen (O2) tubing, resulting in a deficiency. The facility's policy, revised in November 2011, required that O2 cannula and tubing be changed every seven days or as needed to prevent infection. However, for a resident with diagnoses including Bartter's syndrome, chronic obstructive pulmonary disease, and anxiety disorder, the O2 tubing was observed to be dated 11/01/24, indicating it had not been changed in over a month. Interviews with staff revealed inconsistencies in understanding the policy, with an LPN stating the tubing should be changed monthly, while the DON indicated it should be changed bimonthly. The administrator also confirmed the tubing should be changed monthly, highlighting a lack of compliance with the facility's policy.
Failure to Administer Medications Per Physician's Orders
Penalty
Summary
The facility failed to ensure that a diuretic and blood pressure medication were administered according to physician's orders for a resident with diagnoses including hypertension, edema, and dementia. The resident had orders for quinapril, a hypertensive medication, and Lasix, a diuretic, both to be administered daily. However, there were no documented parameters for withholding these medications based on blood pressure readings. During a medication pass, a CMA held both medications due to the resident's low blood pressure, despite the absence of any physician's orders to do so. The Director of Nursing (DON) confirmed that there were no orders specifying parameters for withholding the medications. The facility's policy on medication errors requires the CMA to inform the nurse, who then informs the DON, and the DON informs the doctor, followed by documentation of the error. In this case, the medications were not administered, and the DON acknowledged the lack of orders for holding the medications, indicating a failure to adhere to the facility's policy and physician's orders.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beaver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Booker Hospital District Dba: Twin Oaks Manor | 24.2 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Liberal | 28.6 mi | ★★★★★ | 1 | 0 |
| Southwest Medical Center Snf | 28.7 mi | ★★★★★ | 18 | 0 |
| Wheatridge Park Care Center | 29.5 mi | ★★★★★ | 0 | 0 |
| Capstone Healthcare Of Perryton | 34.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.