Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Valley Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to provide and document consistent bathing assistance for two dependent residents who required staff help with ADLs. One resident with COPD, muscle weakness, and heart failure, and another with a stroke, anemia, and major depressive disorder were each coded on the MDS as fully dependent for bathing. Their Kardexes and care plans scheduled showers or baths on specific evening shifts, with one needing limited assistance and the other total dependence. Review of April records showed multiple scheduled shower days with no documentation that showers or bed baths were provided or refused. The DON confirmed the missing shower documentation, and leadership acknowledged that required ADL bathing services were not consistently provided.
The facility failed to ensure that three residents with Stage 3 and Stage 4 pressure ulcers consistently received and had documented their ordered daily wound treatments. Physician orders directed daily cleansing with NSS, application of collagen or hydrofera blue, and coverage with bordered dressings, but multiple treatment dates were missing from the TARs for each resident. An LPN reported that wound treatments are only documented on the TAR and that there is no other way to verify completion without directly viewing the wound, and the ADON could not provide proof that the missed-date treatments were performed, resulting in a cited failure to provide necessary services to promote pressure ulcer healing.
Infection Prevention and Control Failures: The facility failed to complete required infection surveillance mapping, timely place residents on precautions during Candida auris contact tracing, implement droplet precautions for a resident with COVID-like symptoms, report multiple new COVID cases within 24 hours, and maintain universal source control during a COVID outbreak. During a medication pass, an LPN also failed to perform hand hygiene before, during, and after care for a resident with HTN, DM, and anxiety.
A resident’s Zio monitor order was not discontinued after the device was no longer present, another resident with diabetes and a surgical wound did not receive ordered wound vac care as documented, a third resident continued to receive an expired ACE wrap treatment, and a fourth resident’s accuchecks lacked physician notification parameters for abnormal CBG levels. Staff interviews and record review confirmed the missing order changes and incomplete treatment documentation.
Failure to complete annual performance evaluations for five of five nurse aides was identified during review of personnel records and staff interview. The HR employee confirmed that performance reviews were not completed for NA Employee E1 through E5 as required.
Missing Monthly Medication Regimen Review Documentation: The facility failed to show evidence that the attending physician reviewed monthly MRRs for four residents. Records for residents with diagnoses including depression, schizophrenia, bipolar disorder, diabetes, hypertension, schizoaffective disorder, and anxiety showed multiple psychotropic and other medications, but no pharmacy review documentation was found in the clinical or paper records. The DON confirmed the missing MRR evidence.
Medication Storage and Labeling Deficiencies: The facility failed to store drugs and biologicals in a safe, secure, and orderly manner in one medication room and three medication carts. Observations found expired flu vaccines, an opened vial of tubersol without a date, multiple opened meds and inhalers missing dates, and a Lantus insulin pen not stored in a bag. An RN and LPNs confirmed the findings.
A resident with HTN, DM, and muscle weakness was observed in bed with two packs of Coricidin HBP. An LPN confirmed the resident was left unattended with meds, and another LPN confirmed there was no order or care plan for self-administration. The DON confirmed the facility failed to determine the resident’s ability to self-administer meds.
A resident with heart failure, anxiety, and depression, and who was cognitively intact, experienced an event that was not documented as being reported to the resident’s family or physician. The resident stated family members were not called, and the DON confirmed that neither the resident representative nor the medical provider was notified.
Failure to Provide SNF-ABN for Medicare Non-Covered Services: The facility failed to provide a SNF-ABN for a resident whose Medicare Part A skilled services ended and who later transitioned to another payor source. The resident had anxiety disorder, depressive disorder, and HTN, and the record did not show that the required notice was issued before Medicare coverage ended; the NHA confirmed the omission.
Failure to Identify Wheelchair Devices as Restraints: The facility did not recognize a seat belt, table attached to a wheelchair, or leg straps on a Broda chair as possible restraints for two residents. One resident with CVA, weakness, and HTN was observed with a seat belt across the legs and a table attached, but there was no physician order or documented assessment. Another resident with Huntington’s disease, anemia, and anxiety was observed with thigh straps clipped to the chair, and staff gave conflicting explanations while the DON said the straps were viewed as adaptive equipment rather than a restraint.
Unnecessary Psychotropic Medication Use: A resident with diagnoses including depression and dementia received quetiapine for psychosis even though the record did not include a psychosis diagnosis. The MDS showed antipsychotic use, behavior monitoring documented no behaviors, and psych notes recorded no agitation, hallucinations, delusions, suicidal or homicidal ideations, depression, or anxiety. The NHA and DON confirmed the facility failed to ensure the resident's drug regimen was free from unnecessary drugs used without adequate indications for use.
Improper discharge planning and incorrect ombudsman notification: A resident admitted with anxiety disorder, hyperlipidemia, and respiratory failure had disruptive behaviors and concern for drug use during the stay. The record stated the resident needed case management and social service involvement for home status and that discharge would be to a hotel, then a homeless shelter, but there was no housing referral in the chart. The ombudsman notice listed the resident’s former address instead of the motel/hotel or homeless shelter, and the NHA confirmed the wrong discharge placement was reported.
A resident with HF, anxiety, and depression had an MDS coded to show daily bed rail restraint use, but the clinical record did not include a physician order for bedrail restraints. The resident was observed in bed with bilateral enabler bars, and the MDS Coordinator confirmed the restraint coding was entered in error.
A resident admitted with anemia, HTN, and DM did not have a baseline care plan completed within 48 hours of admission as required by facility policy. The admission record showed the baseline care plan/order review was marked no, and the DON confirmed the care plan was not completed.
A resident with HTN, CVA, and muscle weakness had a physician order for a podiatry consult for toenail trimming, but the resident stated the toenails were long and that no podiatrist had ever been seen. Staff observed thick, elongated, curved toenails extending well beyond the toes, and the DON confirmed the resident had not received podiatry care since admission.
Failure to Provide Ordered PICC Line Care: The facility failed to provide prescribed PICC line care for two residents. One resident had a PICC dressing that was not changed per the ordered 7-day schedule, and another resident had an undated PICC dressing and no documented order for PICC dressing changes. Staff, including an RN, LPNs, and the DON, confirmed the missing or overdue PICC care and documentation.
A resident with ESRD on hemodialysis, DM, and right-sided hemiplegia had repeated gaps in dialysis communication documentation, including missing pre- and post-dialysis forms between the facility and dialysis center. The resident was also ordered a 1200 ml/day fluid restriction, but intake logs showed multiple days above the limit, and an RN confirmed the fluid intake was not maintained as ordered; the DON confirmed the communication and fluid restriction failures.
The facility failed to provide trauma informed care for a resident with PTSD by not identifying PTSD triggers in the care plan. The resident had diagnoses including PTSD, DM, and HF, and the care plan noted bipolar disorder, chronic PTSD, agoraphobia with panic disorder, and anxiety disorder, but did not identify triggers. A Social Services employee confirmed the omission during interview.
Failure to provide medically-related social services for a resident with anxiety, respiratory failure, and opioid dependence. The resident was found in the parking lot with what appeared to be drug paraphernalia and a white substance, yet the record lacked a referral for drug and alcohol treatment or communication with the resident’s clinic. Social Services stated the resident was homeless with no finances and was discharged to a motel/hotel, and the NHA confirmed the facility failed to provide services and did not identify the correct discharge placement to the ombudsman.
The facility failed to ensure residents were free of significant medication errors for two residents. One resident with diabetes and dialysis needs missed multiple ordered meds and treatments on dialysis days, including accuchecks, insulin, and other scheduled medications. Another resident with diabetes received insulin via pen without the LPN priming the pen as required, and the LPN confirmed the omission. The DON acknowledged the errors.
The facility failed to hold QAA/QAPI meetings at least quarterly with all required members for one quarter. Review of minutes, sign-in sheets, and attendance records showed the Medical Director was not present for the quarter one meeting, and the NHA confirmed the required committee membership was not met.
A resident with multiple medical conditions reported to a CRNP that another male resident with dementia entered her room and fondled her breast. Although administration and nursing leadership were made aware, there was no evidence that the incident was reported to authorities or that a formal abuse investigation was conducted, in violation of required protocols.
A resident with multiple medical conditions reported being inappropriately touched by another resident with dementia. Despite facility policy requiring prompt and thorough investigation of abuse allegations, there was no evidence of a completed investigation, documentation, or actions taken to ensure resident safety. Staff interviews confirmed awareness of the incident but did not provide supporting documentation.
The facility failed to meet the required nurse aide staffing levels on three days, resulting in a deficiency. On one night shift, only 48 hours of care were provided instead of the required 56 hours for 105 residents. On another day, the daylight shift required 84.80 hours, but only 56 hours were provided, and the evening shift required 77.09 hours, with only 53.25 hours provided for 106 residents. On a subsequent day, the daylight shift required 84.80 hours, but only 71.58 hours were provided for 106 residents.
The facility failed to provide the required staffing levels for nurse aides on three days and did not meet the mandated 3.2 hours of direct resident care per resident on one day. The Nursing Home Administrator confirmed these deficiencies.
A facility failed to assess a resident's ability to self-administer medications, as required by their policy. A resident with acute kidney failure, anemia, and hypertension was found with Ivizia eye drops on the bedside stand without orders for self-administration. An LPN confirmed the lack of orders and removed the medication.
The facility failed to communicate necessary information to receiving health care providers for two residents transferred to the hospital. The required documentation, including care plan goals and specific instructions for ongoing care, was not provided, as confirmed by the Nursing Home Administrator.
The facility failed to provide written notification of its bed-hold policy to two residents or their representatives upon hospital transfer. Despite policy requirements, there was no documented evidence of notification for a resident with anxiety and high blood pressure, and another with Alzheimer's and wheelchair dependence. The Nursing Home Administrator confirmed the oversight.
A facility failed to include necessary interventions for skin sleeves in a resident's care plan, despite the resident's diagnoses of heart failure, hypertension, and diabetes. The omission was confirmed by the DON, highlighting a lapse in adhering to the facility's policy for comprehensive, person-centered care planning.
The facility failed to obtain physician orders for treatments for two residents. One resident with heart failure, hypertension, and diabetes was observed with skin sleeves without a physician order. Another resident with dementia, heart failure, and dysphagia had an NPO diet due to choking risks, but lacked a physician order for this status. The DON confirmed these deficiencies.
Two residents with urinary catheters experienced deficiencies in care at the facility. A resident with a history of hypertension and neurogenic bladder was found with a Foley catheter bag lacking a dignity/privacy cover, contrary to facility policy. Another resident with dementia and heart failure had a Foley catheter inserted without a physician order, as confirmed by an LPN. These incidents highlight failures in adhering to catheter care and documentation policies.
A facility failed to maintain sanitary conditions for a resident's respiratory equipment. The nebulization machine was not stored in a labeled bag, and the oxygen concentrator's humidifying jar was empty. An LPN confirmed these deficiencies, which did not comply with the facility's policies for respiratory care.
The facility failed to provide trauma-informed care for two residents with PTSD by not identifying or mitigating triggers in their care plans. Despite the facility's policy on trauma-informed care, the care plans lacked specific strategies to prevent re-traumatization, as confirmed by the Social Service Director.
The facility failed to conduct ongoing assessments for two residents using bed rails, as required by federal regulations and facility policy. Despite having conditions like anemia, hypertension, parkinsonism, and diabetes, the residents' bed rail evaluations were outdated, with the last assessments recorded months prior. This oversight was confirmed by the DON and NHA, highlighting a lapse in ensuring resident safety and compliance with care standards.
A facility failed to properly store medications and biologicals in a medication cart. Items found included unlabeled vials and bottles, personal drinks, and a medicine cup with various tablets. An RN confirmed these observations, noting the medicine cup belonged to a sleeping resident and the drinks were personal.
The facility failed to implement proper infection control measures during a COVID-19 outbreak for a resident who was not tested promptly despite symptoms. Additionally, an LPN did not adhere to infection control practices during a dressing change for another resident, leading to potential cross-contamination.
The facility failed to notify the Office of the LTC Ombudsman Division about the hospital transfers of two residents, as required by policy. Both residents, one with vascular dementia and another with end-stage renal disease, were transferred without the necessary notification. Interviews with staff revealed a lack of awareness about this requirement.
A resident with Vascular Dementia and other conditions was not readmitted to the facility after hospitalization due to increased behaviors and the need for a secure unit. The facility failed to provide formal discharge notice or evidence that they could not meet the resident's needs, as confirmed by staff interviews and the Nursing Home Administrator.
The facility failed to provide sufficient staffing, resulting in delayed call light responses and inadequate personal hygiene care for several residents. Residents reported long wait times for assistance, with some waiting over an hour. Observations showed residents in nightgowns or hospital gowns, and shower records indicated missed or undocumented showers. The Nursing Home Administrator confirmed the staffing inadequacy.
Failure to Provide and Document Consistent Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide and document consistent assistance with bathing ADLs for two dependent residents. Facility policy dated 12/22/25 required that residents who are unable to carry out ADLs independently receive services necessary to maintain grooming and personal hygiene. Resident R2, admitted 1/15/18, had diagnoses including COPD, muscle weakness, and heart failure. On the MDS dated 2/13/26, Section GG0130E coded the resident as 01, indicating dependence on a helper for all effort or the need for two or more helpers. The Kardex and care plan identified scheduled showers or baths on Tuesday and Friday evening shifts with limited assistance. Review of April 2026 documentation showed that on multiple scheduled shower days (4/3, 4/14, 4/17, 4/21, and 4/24), there was no documentation that the resident received or refused a shower or bed bath. The DON confirmed that shower documentation for these dates was incomplete. Resident R3, admitted 1/12/24, had diagnoses including cerebral infarction affecting the left side, anemia, and major depressive disorder. The MDS Section GG0130E also coded this resident as 01, indicating total dependence on staff for the activity. The Kardex and care plan showed the resident was scheduled for showers or baths on Wednesday and Sunday evening shifts with total dependence for bathing. Review of April 2026 records revealed missing documentation for scheduled shower days (4/8, 4/15, and 4/22), with no indication that the resident received or refused a shower or bed bath. In interviews, the DON acknowledged the incomplete shower documentation for both residents, and the NHA and DON stated that the facility failed to provide assistance with ADLs involving consistent showers or baths for these two residents, in violation of 28 Pa. Code 211.10(d) and 211.12(c)(d)(1)(3)(5).
Failure to Provide and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide and document necessary pressure ulcer treatments in accordance with physician orders and facility wound care policy for three residents with pressure injuries. The facility’s wound care policy required documentation in the medical record of the type of wound, date and time wound care was given, changes in condition, resident complaints, and refusals with reasons. One resident with spinal stenosis, diabetes, hypertension, and peripheral vascular disease had a documented Stage 4 coccyx wound, with physician orders to cleanse with normal saline, apply collagen with silver, and cover with bordered gauze every day on the day shift. Review of the February Treatment Administration Record (TAR) showed no documented wound treatments on three specific dates, despite the standing daily order. A second resident with diabetes, general weakness, and hyperlipidemia had a Stage 3 coccyx pressure area with orders to cleanse with normal saline, apply hydrofera blue, and cover with bordered gauze every day on the day shift; the February TAR lacked documentation of wound treatments on four specified dates. A third resident with diabetes, COPD, morbid obesity, and hyperlipidemia had a Stage 3 sacral pressure area with orders to cleanse with normal saline, apply collagen particles, and cover with a bordered dressing every day on the day shift; the February TAR showed missing wound treatments on three dates. During interviews, an LPN stated that wound treatments are documented on the TAR and that, unless the area is directly assessed, there is no other way to know if treatments were done. When asked, the ADON could not provide proof of wound treatments for the three residents, and surveyors informed facility leadership that the facility failed to ensure residents received necessary treatment and services consistent with professional standards to promote healing of pressure ulcers.
Infection Prevention and Control Failures
Penalty
Summary
The facility failed to conduct infection surveillance mapping for multiple months, including October 2024, February 2025, April 2025, August 2025, and September 2025. The surveillance tracking and mapping also failed to include a room on the April 2025 map and did not include tracking for Candida auris-positive residents R45 and R59 in August 2025. The facility’s surveillance policy stated the Infection Preventionist was to conduct ongoing surveillance for healthcare-associated infections and other significant infections, with monthly collection, summary, and analysis of infection data. The facility also failed to timely implement isolation precautions during Candida auris contact tracing testing. On 8/15/25, the facility was notified that a resident tested positive for Candida auris and that further testing would be needed for all current residents on the first floor. Resident R45 and Resident R59 were tested on 8/27/25, and their clinical records showed enhanced barrier precautions were not ordered until 9/3/25, eight days after preliminary testing occurred. The Pennsylvania Department of Health toolkit stated residents require preemptive contact precautions while lab results are pending, including placement in a private room if possible and use of gown and gloves by staff entering the room. During a COVID outbreak, the facility failed to timely implement droplet precautions for Resident R116, who began having fever, cough, and chills on 8/18/25 and tested positive for COVID on 8/20/25. The resident’s record from 8/18/25 through 8/20/25 did not show droplet precautions were implemented for the COVID-like symptoms. The facility also failed to report newly identified COVID cases within 24 hours for Nurse Aide Employee E16, Nurse Aide Employee E24, and Residents R50, R51, R54, and R91. Observations from 9/22/25 through 9/24/25 showed staff and residents were not wearing source control throughout the facility during the outbreak, and the DON confirmed the facility failed to implement universal source control. In addition, during a medication pass for Resident R91, an LPN failed to perform hand hygiene prior to, during, and after the medication pass, and the LPN confirmed this during interview. Resident R91’s MDS listed diagnoses of hypertension, diabetes, and anxiety.
Failure to discontinue expired orders and provide ordered wound and diabetes care
Penalty
Summary
The facility failed to discontinue a physician order for a resident who no longer had the ordered Zio monitor. Resident R2 was admitted with diagnoses including hemiplegia and aphasia following cerebral infarction, muscle weakness, and other chronic conditions. A physician order dated 8/25/25 directed staff to monitor the Zio patch every shift for errors or dislodgement and to notify the MD and customer service if problems were noted. The TAR and nurses’ notes showed entries on 9/20/25, 9/21/25, and 9/22/25 indicating the monitor was not present, and the resident’s husband stated the monitor had already been taken back days earlier. The DON confirmed the order had not been discontinued as required. The facility also failed to provide appropriate care and services for Resident R16’s wound vac treatment. Resident R16 had diagnoses including diabetes, high blood pressure, and orthopedic aftercare following surgical amputation. A nurse practitioner note directed cleansing the left plantar open surgical wound with normal saline and applying the wound vac three times per week, and the active order listed wound vac therapy at 125 mmHg on Monday, Wednesday, and Friday. However, the order did not include cleansing, black foam, drape application, or a wet-to-dry dressing if the wound vac malfunctioned, and the care plan also lacked those interventions. Staff interviews and record review showed the wound vac dressing was not changed on 9/24/25, and the record failed to show the left foot wound was cleansed from 9/10/25 through 9/24/25. The facility failed to discontinue skin treatments for Resident R32 and failed to obtain physician order parameters for blood glucose notifications for Resident R89. Resident R32 had diagnoses including diabetes, hyperlipidemia, and hypertension, and had an ACE wrap order for the left elbow for bursitis that ended on 9/11/25, yet progress notes later documented continued daily use of ACE wraps and the resident was observed wearing the wrap weeks later; an LPN stated there was no current order and that the resident insisted on the wrapping. Resident R89 had diabetes on insulin, hemiplegia, and renal dialysis dependence, and the physician orders included accuchecks before meals but did not include parameters for when to notify the physician of increased or decreased CBG levels. The DON confirmed those notification parameters were not included.
Failure to Complete Annual Nurse Aide Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for five of five nurse aides, identified as NA Employee E1, E2, E3, E4, and E5. Review of personnel records and staff interview showed that the required performance reviews were not present for these nurse aides. During an interview, the Human Resource Employee E6 confirmed that the facility did not have performance reviews completed for NA Employee E1 through E5 and acknowledged that annual performance evaluations had not been completed for five of five nurse aides as required.
Missing Monthly Medication Regimen Review Documentation
Penalty
Summary
The facility failed to provide evidence that medication regimen reviews (MRR) were reviewed by the residents’ attending physician monthly for four residents: R6, R10, R11, and R59. The consultant pharmacist’s monthly report of pharmaceutical services was last reviewed on 7/11/25 and stated that the consultant pharmacist prepares monthly written reports on the status of the facility’s pharmaceutical services and nursing staff performance related to medication therapy, with monthly reports kept on file for at least two years. However, review of the clinical record and paper records for these residents did not include pharmacy reviews related to medication therapy or MRR documentation reviewed by the physician. Resident R6 had diagnoses including depression, schizophrenia, and high blood pressure, and was ordered Cymbalta 30 mg at bedtime, Cymbalta 60 mg in the morning, and Abilify 5 mg at bedtime, with a care plan to attempt psychotropic drug reduction. Resident R10 had diagnoses including bipolar disorder, diabetes, and hypertension, and was receiving Ativan 0.5 mg, Klonopin 0.5 mg, Melatonin 5 mg, and Tramadol 50 mg. Resident R11 had diagnoses including diabetes, schizoaffective disorder, and depressive disorder, and was ordered Abilify 10 mg, Buspirone 15 mg, Gabapentin 100 mg, and Melatonin 5 mg. Resident R59 had diagnoses including major depressive disorder, anxiety disorder, and spinal stenosis, and her record showed Sertraline 100 mg daily and Lorazepam 0.5 mg twice daily, but no MRR was found in the clinical record. During interview, the DON confirmed the facility failed to provide evidence that MRRs were reviewed by the attending physician monthly for these four residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store drugs and biologicals in a safe, secure, and orderly manner in one of two medication rooms and three of five medication carts. Facility policies reviewed indicated that medications and biologicals are to be stored safely and securely, that expiration or beyond-use dates are checked before administration, and that when a multi-dose container is opened the date is recorded on the container. The policy for insulin pen administration also indicated that the pen cap should be removed and the medication expiration date and overall appearance of the pen and insulin checked. During an observation of the first-floor medication room, items were found stored under the sink, including a white basket with three blood spill kits and a flashlight, one bottle of drug buster, one box of gloves, one clear plastic lock box, three medication cart trash container lids, and a roll of plastic bags. The refrigerator contained three boxes of Sanofi Pasteur high dose flu vaccine and three boxes of Sanofi Pasteur low dose flu vaccine, all with an expiration date of 6/25, as well as one opened vial of tubersol that was not labeled with a date. The freezer section contained six Nordic ice packs and two instant ice packs. In the second-floor South medication cart, opened bottles of Pepto Bismol, Geri-tussin, milk of magnesia, artificial tears, and timolol eye drops, along with two opened albuterol inhalers, were all missing dates. The first-floor South medication cart contained an opened trilogy inhaler that was not labeled with a date, and the first-floor [NAME] medication cart contained a Lantus insulin pen that was not stored in a bag. Staff members confirmed each of these findings during interviews.
Failure to Determine Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine whether Resident R16 could safely self-administer medications. The resident had diagnoses of high blood pressure, diabetes, and muscle weakness, and the clinical record showed admission and readmission to the facility. On 9/23/25 at 11:34 a.m., Resident R16 was observed in bed with two packs of red pills labeled Coricidin HBP. During interviews later that morning, an LPN confirmed the resident was left unattended with medications, and another LPN confirmed there was no order for the medication or care plan for self-administration of medications. The DON also confirmed the facility failed to determine the ability to self-administer medications for one of six residents.
Failure to Notify Family and Physician of Resident Event
Penalty
Summary
The facility failed to notify the resident representative and/or medical provider of a change in condition/status for one resident, R66. The facility policy on accidents and incidents stated that all accidents or incidents involving residents should be investigated and reported, and that the date/time the family was notified and by whom, as well as the time the attending physician was notified and the physician’s response and instructions, should be documented. Resident R66 was admitted to the facility with diagnoses of heart failure, anxiety, and depression, and had a BIMS score of 13, indicating cognitive intactness. The resident’s demographic profile listed a son as the emergency contact. After a recent event involving R66 on 9/21/25, the resident stated that family members were not called and did not even know about it. Review of the progress notes for that event did not include family or physician notification, and the DON confirmed during interview that neither the family member nor the physician received notification.
Failure to Provide SNF-ABN for Medicare Non-Covered Services
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF-ABN) for one sampled closed resident record, CR132. Facility policy stated that the purpose of a SNF-ABN is to inform the Medicare beneficiary that Medicare may not pay for particular services, and that if the resident continues in the nursing facility under a different payor source, a current SNF-ABN letter is to be issued on or before the last covered day. CR132 was admitted on [DATE] and had diagnoses that included anxiety disorder, depressive disorder, and hypertension. The record showed that Medicare Part A skilled services began on 3/7/25 and ended on 3/13/25. Review of the clinical record did not show that CR132 was provided a SNF-ABN before the Medicare Part A services ended. CR132 was later discharged to personal care on 5/2/25. During interview, the Nursing Home Administrator confirmed that the facility failed to provide the SNF-ABN as required.
Failure to Identify Wheelchair Devices as Possible Restraints
Penalty
Summary
The facility failed to identify a seat belt and table attached to a wheelchair, and leg straps placed over a resident’s thighs, as possible restraints, and failed to assess the residents’ functional status to determine whether those devices were restraints for two residents. The facility policy stated that restraints are based on the resident’s functional status, not the device itself, and that devices such as trays, tables, and belts that the resident cannot remove and that prevent rising may be considered restraints. The policy also stated restraints require a physician order, resident or representative consent, and regular review for reduction or elimination. Resident R15 had diagnoses including high blood pressure, cerebral infarction, and muscle weakness. The resident’s care plan listed wheelchair use as assistive/adaptive equipment but did not describe the equipment or its purpose. During observation, R15 was sitting in a wheelchair with a seat belt across the legs and a table attached to the left side. The active physician orders did not include an order for the seat belt or table, and the clinical record did not contain assessments, ongoing evaluations, or documentation identifying the medical symptom being treated or the specific order for the seat belt and table. Resident R58 had diagnoses including Huntington’s disease, anemia, and anxiety. The care plan also listed wheelchair use as assistive/adaptive equipment without describing the equipment or its purpose. During observation, R58 was sitting in a Broda chair with two burgundy leg straps placed over the thighs and clipped to the back of the chair. Staff interviews showed uncertainty about the straps: one LPN stated hospice orders the chairs and thought the straps were used because the resident slides, another LPN said she did not know why the resident had straps and expected to see orders, the rehab director stated the straps would be considered a restraint and that the resident could not remove them, and the DON stated the straps were not considered a restraint because they came with the chair and were viewed as adaptive equipment. On interview, the DON confirmed the facility failed to identify the devices as possible restraints and failed to assess the residents’ functional status for restraint determination.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary psychotropic medications used without adequate indications for use for one resident, R98. Review of the admission record showed the resident was admitted to the facility and had diagnoses including depression, metabolic encephalopathy, and dementia. The MDS assessment dated [DATE] showed antipsychotic medication use in the seven days before the assessment, while the facility diagnosis list included dementia in other diseases classified elsewhere, mild, with anxiety. No psychotic diagnoses were present on the MDS, and the clinical record did not include a diagnosis of psychosis. A physician order dated 7/8/25, discontinued 8/27/25, directed quetiapine 100 mg, two tablets by mouth at bedtime for psychosis, and the active order dated 8/27/25 directed quetiapine 100 mg, one tablet by mouth at bedtime for psychosis. Behavior monitoring documentation from 7/8/25 through 9/23/25 showed no behaviors documented for each shift. A psychiatric progress note dated 7/30/25 stated the resident's spouse reported the resident had been on quetiapine for about two years and felt it continued to be beneficial. A psychiatric progress note dated 9/2/25 documented that the resident denied suicidal and homicidal ideations, agitation, hallucinations, delusions, depression, and anxiety. The NHA and DON confirmed on 9/24/25 that the facility failed to ensure the resident's drug regimen was free from unnecessary drugs used without adequate indications for use.
Improper discharge planning and incorrect ombudsman notification
Penalty
Summary
The facility failed to ensure an appropriate discharge for Closed Record Resident R131 and failed to notify the ombudsman of the correct living arrangement. Resident R131 was admitted from the hospital with diagnoses including anxiety disorder, hyperlipidemia, and respiratory failure. Facility documentation stated that the resident had a couple-day period of disruptive behaviors and concern for drug use, although the UDS was negative. The discharge summary indicated the resident needed case management and social service involvement regarding current home status and that he was discharging to a hotel for now, then followed by a homeless shelter. Clinical record review showed the resident was in a program called Crossroads, described as a drug and alcohol treatment facility, and the record failed to include a referral for housing. Facility documentation also included a notice to the ombudsman office for a 30-day discharge, but the address listed on the form was the resident’s former address rather than the motel/hotel or homeless shelter. During interview, the Social Services employee confirmed the resident had been admitted with housing listed as homeless, had no finances while at the facility, and was discharged to a motel/hotel. The Nursing Home Administrator later confirmed the facility failed to identify a housing facility for the resident and failed to identify the correct discharge placement to the ombudsman.
MDS Assessment Incorrectly Coded for Bed Rail Restraint
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected a resident’s status for one of four residents reviewed. The facility policy on certifying accuracy of the Resident Assessment stated that any person completing a portion of the MDS must sign and certify the accuracy of that portion. Resident R8 was admitted with diagnoses of heart failure, anxiety, and depression. The resident’s MDS coded Section P0100, Physical Restraints used in bed, as a bed rail used daily. However, the clinical record did not include a physician order for bedrail restraints, and the facility-provided resident matrix identified the resident as having a physical restraint. During observation, the resident was in bed with bilateral enabler bars noted. During interview, the MDS Coordinator confirmed the MDS was coded for restraint use and stated, "oh I can't believe I did that; it was probably when I was working off my phone," confirming the assessment did not accurately reflect the resident’s status.
Failure to Complete Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan for Resident R4 within 48 hours of admission. Facility policy titled Care Plans-Baseline, last reviewed 7/11/25, stated that a baseline plan of care to meet a resident's immediate needs shall be developed for each resident within 48 hours of admission and used until the comprehensive assessment and interdisciplinary person-centered care plan are completed. Review of the clinical record showed Resident R4 was admitted on [DATE], and the MDS dated 8/6/25 listed diagnoses of anemia, high blood pressure, and diabetes. The admission evaluation section 9 baseline care plan/order review was marked no, indicating the baseline care plan was not completed. During an interview on 9/24/25 at 12:57 p.m., the DON confirmed that Resident R4's baseline care plan was not completed as required.
Failure to Provide Ordered Podiatry Care
Penalty
Summary
The facility failed to provide appropriate foot care to Resident R15. The facility’s Foot Care policy stated residents would receive appropriate care and treatment to maintain mobility and foot health, and that residents would be assisted with transportation appointments to podiatrists as needed. Resident R15 was admitted with diagnoses including high blood pressure, cerebral infarction, and muscle weakness, and a physician order dated 6/3/25 directed a podiatry consult for toenail trimming. During interview and observation on 9/23/25, the resident stated the toenails were long and that the resident had never seen a podiatrist. The resident was observed with overgrown toenails, and a nurse aide confirmed the toenails were thick, elongated, and curved, measuring approximately one-half inch to one inch beyond the ends of the toes. The ADON stated residents with Medicare/Medicaid see podiatry in-house and skilled residents are sent to the community, and the DON confirmed the resident had not received podiatry care since admission.
Failure to Provide Ordered PICC Line Care
Penalty
Summary
The facility failed to provide prescribed treatment and services related to PICC line care for two residents. Resident R16 was admitted and later readmitted to the facility, and his MDS listed diagnoses including high blood pressure, diabetes, and encounter for orthopedic aftercare following surgical amputation. His care plan directed staff to change the IV site dressing per physician order and as needed if soiled or wet, and a physician order dated 9/10/25 directed that the PICC dressing and caps be changed every seven days. Although the TAR documented that RN E9 changed the dressing on 9/17/25, an observation on 9/24/25 at 2:33 p.m. showed the PICC dressing dated 9/9/25, and LPN E8 confirmed the dressing date and that the facility failed to change it as ordered. Resident R42 was admitted and later readmitted to the facility, and his MDS listed diagnoses including high blood pressure, muscle weakness, and pneumonia. His care plan also directed staff to change the IV site dressing per physician order and as needed if soiled or wet. On 9/22/25, the physician orders reviewed did not include an order to change the PICC dressing and caps every seven days. During an observation that day at 11:11 a.m., Resident R42's upper left arm PICC dressing was undated. RN E10 confirmed the dressing was undated, and LPN E11 stated that orders to change IV dressings are located in the electronic record and confirmed Resident R42 did not have an order for the PICC line or for changing the PICC dressing. The DON later confirmed the facility failed to provide prescribed treatment and services related to PICC line care for both residents.
Dialysis Communication and Fluid Restriction Not Maintained
Penalty
Summary
Failure to provide safe, appropriate dialysis care/services was identified for one resident who had diabetes, right-sided hemiplegia, and dependence on renal dialysis. The resident had physician orders to receive hemodialysis every Monday, Wednesday, and Friday, with full vital signs obtained before dialysis and vital signs obtained after dialysis on those days. The care plan directed staff to coordinate dialysis care with the dialysis treatment facility and to obtain pre- and post-dialysis vital signs. Review of dialysis communication forms from 8/1/25 through 9/22/25 showed repeated gaps in communication and documentation, including multiple dates when the form was not completed by the facility nurse upon return from dialysis, several dates when the dialysis facility did not complete the form, and one date when neither the dialysis facility nor the facility nurse completed it. The facility also failed to maintain the resident’s ordered 1200 ml daily fluid restriction. The physician order specified 840 ml from dietary sources and additional nursing fluid limits by shift, with documentation required in ml for shift and daily totals. The resident’s care plan identified risk for altered hydration related to fluid restriction and included monitoring for signs of fluid overload and edema. Review of the fluid intake log showed recorded daily totals above the ordered limit on multiple dates, including 1840 ml, 1960 ml, 1574 ml, 1640 ml, 1530 ml, 1590 ml, 1550 ml, 1780 ml, and 1460 ml. During interview, an RN stated the fluid amount recorded was a combination of dietary and nursing intake, and confirmed the resident’s fluid intake was not maintained as ordered. The DON also confirmed the facility failed to make certain consistent dialysis communication was maintained and ensured fluid restrictions were maintained for the resident.
Failure to Identify PTSD Triggers in Care Plan
Penalty
Summary
The facility failed to provide trauma informed care for a resident with post-traumatic stress disorder (PTSD) by not identifying PTSD triggers in the resident’s care plan. Resident R1 was admitted with diagnoses including PTSD, diabetes, and heart failure, and the MDS dated 8/2/25 indicated the diagnoses were current. The care plan dated 7/18/22 identified the resident as at risk for changes in mood related to bipolar disorder, chronic PTSD, agoraphobia with panic disorder, and anxiety disorder, but it did not identify PTSD triggers for the resident. During an interview on 9/26/25, Social Services Employee E24 confirmed that the facility failed to identify PTSD triggers for Resident R1 and failed to provide trauma informed care to eliminate or mitigate triggers that may cause re-traumatization.
Failure to Provide Medically-Related Social Services for Resident with Opioid Dependence
Penalty
Summary
Medically-related social services were not provided for Closed Record Resident R131. The resident’s MDS dated 3/23/25 listed diagnoses of anxiety disorder, hyperlipidemia, and respiratory failure. Facility documentation showed that on 4/2/25 the resident was found in the parking lot with what appeared to be aluminum foil shaped into a pipe and a white substance. A clinical record follow-up dated 4/11/25 documented active medical problems including opioid dependence and noted the resident was on chronic Suboxone 8-2 mg three times daily, with a script sent electronically for a 2-week supply to be given at discharge and then followed up with the clinic. The diagnosis was listed as opioid dependence, uncomplicated. During interview, Social Services staff stated the resident was admitted with housing, was listed as homeless, had no finances while a resident, and was discharged to a motel/hotel. Review of the clinical record did not include a referral for drug and alcohol treatment or any communication with Crossroads clinic, despite the record noting the resident received medication at that clinic. The Nursing Home Administrator confirmed the facility failed to provide services for the resident and failed to identify the correct discharge placement to the ombudsman.
Medication administration errors involving missed doses and improper insulin pen use
Penalty
Summary
The facility failed to ensure that residents were free of significant medication errors for two of five residents reviewed. Facility policy required medications to be administered as prescribed, in accordance with written physician orders and good nursing principles, and the insulin pen policy required a safety test before each dose, including priming the pen needle to confirm insulin flow. The report identified that Resident R89 had diagnoses including diabetes, right-sided hemiplegia, and dependence on renal dialysis, with orders for dialysis on Monday, Wednesday, and Friday and permission to give morning medications after return from dialysis. For Resident R89, the September MAR showed multiple medications and procedures were not completed and were coded as missed on dialysis days, including accuchecks, sevelamer carbonate, Humalog insulin, Lantus insulin, acetaminophen, aspirin, gabapentin, and levetiracetam. Nursing notes documented dialysis as the reason for the missed items. For Resident R91, who had diagnoses including high blood pressure, diabetes, and anxiety, an order directed insulin aspart 10 units subcutaneously before meals. During medication observation, an LPN failed to prime the insulin pen as required, and the LPN confirmed the omission during interview. The DON confirmed the facility failed to ensure residents were free of significant medication errors for these two residents.
QAA Meetings Lacked Required Medical Director Attendance
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for one of three quarters in 2025. Review of the facility’s Quality Assurance and Performance Improvement (QAPI) Plan dated 7/11/25 showed that the facility was to maintain an ongoing, facility-wide QAPI plan to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. However, review of Quality Assurance and Performance minutes, sign-in sheets, and attendance records for Quarter One of 2025 did not show the Medical Director in attendance. During an interview on 9/26/25 at 1:15 p.m., the NHA confirmed that the facility failed to conduct QAPI meetings at least quarterly with all required committee members for Quarter One of 2025, as required.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident, as required by its abuse investigation and reporting policy. The policy mandates prompt reporting of all abuse allegations to local, state, and federal agencies, as well as thorough investigation and documentation. In this case, a resident with multiple medical conditions, including diabetes, hypothyroidism, and congestive heart failure, reported to a Certified Registered Nurse Practitioner (CRNP) that another male resident with dementia entered her room and fondled her breast. The CRNP documented the incident and noted that the administration was aware and investigating. However, there was no evidence in the resident's clinical records or facility documentation that an abuse investigation was conducted or that the incident was reported to the appropriate authorities. Further review of facility records from December 2024 to March 2025 confirmed the absence of required notifications to the local State field office, police department, or Department of Aging regarding the allegation. Staff interviews corroborated that the incident was discussed with administration and nursing leadership, but no formal report or investigation documentation was found. This failure to report and document the allegation of sexual abuse constitutes a violation of state regulations regarding the responsibility of management to ensure timely reporting and investigation of abuse allegations.
Failure to Investigate and Document Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who reported that another male resident with dementia entered her room and fondled her breast. The resident, who had diagnoses including an injury to the right Achilles tendon, diabetes, hypothyroidism, and congestive heart failure, was upset by the incident but denied physical injury. Although the facility's policy requires prompt reporting and thorough investigation of all abuse allegations, there was no evidence in the clinical or social services records, or in the facility's abuse investigation documents, that an investigation was conducted or reported as required. Specifically, the documentation lacked a signed statement from the resident, identification of the alleged perpetrator, staff statements, actions to prevent recurrence, measures to ensure resident safety, interviews with other residents, and an assessment of the other resident involved. Interviews with facility staff confirmed awareness of the allegation but did not provide evidence of a completed investigation or appropriate documentation, as required by facility policy and state regulations.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides on three specific days, resulting in a deficiency. On December 13, 2024, during the night shift, the facility provided only 48 hours of nurse aide care when 56 hours were required for a census of 105 residents. On December 14, 2024, the daylight shift required 84.80 hours of nurse aide care, but only 56 hours were provided, and the evening shift required 77.09 hours, with only 53.25 hours provided, for a census of 106 residents. On December 15, 2024, the daylight shift required 84.80 hours of nurse aide care, but the facility provided only 71.58 hours for a census of 106 residents. These deficiencies were identified through a review of nursing schedules and census information, indicating that the facility administrative staff failed to ensure adequate staffing levels as per the regulatory requirements effective July 1, 2024.
Plan Of Correction
The facility will continue to take measures to adequately staff nurses' aides to meet the staffing requirement. The Nursing Home Administrator or designee will conduct a daily labor meeting and audit the nurses' aide schedule to ensure the nurses' aide to resident ratio is met. The Department of Health staffing worksheet will be utilized at this meeting. Re-education will be completed by the Nursing Home Administrator or designee, on the nurses' aide to resident ratio with the Director of Nursing and the Assistant Director of Nursing. The Facility will continue to post open positions on hiring forums. The facility will continue to interview and hire nurses' aides to meet the facility needs.
Staffing and Care Hours Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides on three specific days, namely 12/13/24, 12/14/24, and 12/15/24. During these days, the facility did not provide the minimum number of nurse aides per resident during the day, evening, and night shifts as mandated. Additionally, on 12/14/24, the facility did not meet the required 3.2 hours of direct resident care per resident in a 24-hour period, providing only 2.94 hours per resident with a census of 106. This deficiency was confirmed by the Nursing Home Administrator during an interview on 12/19/24.
Plan Of Correction
The facility will continue to take measures to adequately staff to meet the minimum of 3.2 hours of direct care for each resident. The Nursing Home Administrator will conduct a daily labor meeting and audit the staffing schedule to ensure the minimum hours of direct care for each resident is met. The Department of Health staffing worksheet will be utilized at this meeting. Re-education will be completed by the Nursing Home Administrator or designee with the Director of Nursing and the Assistant Director of Nursing, on the state mandate for minimum hours of direct care for each resident in a 24-hour period. The Facility will continue to post open positions on hiring forums. The facility will continue to interview and hire nurses' aides to meet the facility needs.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to determine the ability of a resident, identified as Resident R96, to self-administer medications. According to the facility's policy dated 8/1/24, residents have the right to self-administer medications if deemed clinically appropriate and safe by the interdisciplinary team. However, it was observed on 9/3/24 that Resident R96 had a box of Ivizia eye drops on the bedside stand, which should not have been there as the resident did not have orders for medication self-administration. This was confirmed by LPN E4, who removed the eye drops and acknowledged the lack of orders for self-administration. Resident R96 was admitted to the facility with diagnoses including acute kidney failure, anemia, and hypertension. The failure to assess and document the resident's ability to self-administer medications led to the presence of unauthorized medication in the resident's room, which was against the facility's policy.
Failure to Communicate Necessary Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for two residents who were transferred from the facility. The facility's policy on transfer or discharge documentation requires that specific information, such as the basis for transfer, medication disposition, care plan goals, and other necessary details, be documented and communicated to the receiving facility. However, for Resident R21, who was admitted with diagnoses including anxiety, weakness, and high blood pressure, and was transferred to the hospital due to shortness of breath and weakness, there was no documented evidence that the required information was communicated. Similarly, Resident R60, who had diagnoses of high blood pressure, Alzheimer's disease, and dependence on a wheelchair, was transferred to the hospital and later returned to the facility. The clinical record for Resident R60 also lacked evidence of communication of necessary information to the receiving health care provider. During an interview, the Nursing Home Administrator confirmed the absence of documentation for both residents, indicating a failure to comply with the facility's policy and regulatory requirements.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon transfer to a hospital or during therapeutic leave. This deficiency was identified for two residents, R21 and R60, during a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 8/1/24, mandates that residents or their responsible parties be informed of bed-hold options and associated financial liabilities at admission and each time a resident is absent from the facility. However, the clinical records for both residents lacked documented evidence of such notifications. Resident R21, who was admitted with diagnoses including anxiety, weakness, and high blood pressure, was transferred to the hospital on 3/10/24 without receiving the required bed-hold policy notification. Similarly, Resident R60, with diagnoses of high blood pressure, Alzheimer's disease, and wheelchair dependence, was transferred to the hospital on 6/2/24 without documented evidence of notification. The Nursing Home Administrator confirmed during an interview that the facility was not completing bed-hold notifications, acknowledging the absence of written notifications for both residents.
Failure to Include Skin Sleeves in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R28, which included necessary interventions for maintaining the resident's highest practicable physical well-being. The resident, who had re-entered the facility with diagnoses of heart failure, hypertension, and diabetes, was observed wearing bilateral skin sleeves. However, the care plan did not include any interventions related to the use of these skin sleeves. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the omission in the care plan. The facility's policy, dated 8/1/24, mandates the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's physical, psychosocial, and functional needs. Despite this policy, the care plan for Resident R28 lacked specific goals and interventions for the skin sleeves, which are essential for the resident's care.
Lack of Physician Orders for Resident Treatments
Penalty
Summary
The facility failed to ensure that a resident had a physician order for treatments they were receiving, affecting two of five residents. Resident R28, who had diagnoses of heart failure, hypertension, and diabetes, was observed wearing bilateral skin sleeves without a corresponding physician order. This was confirmed by the Director of Nursing during an interview, indicating a lapse in obtaining necessary physician orders for the resident's treatment. Additionally, Resident R260, diagnosed with dementia, heart failure, and dysphagia, was noted to have a diet order of NPO (nothing by mouth) due to choking incidents and failed swallow studies. However, the physician order for this diet was missing from the resident's records. Interviews with a Nurse Aide and an LPN confirmed that the resident did not take anything by mouth, and the Director of Nursing acknowledged the absence of a physician order for the NPO status. This deficiency highlights the facility's failure to provide care and services needed for the resident to maintain the highest practicable physical well-being.
Deficiencies in Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with urinary catheters. Resident R37, who has a history of hypertension, neurogenic bladder, and orthostatic hypotension, was observed with a Foley catheter bag hanging from the bedframe without a dignity/privacy cover. This was confirmed by an LPN, indicating a lack of adherence to the facility's catheter care policy, which requires the catheter bag to be covered for privacy and dignity. Resident R260, diagnosed with dementia, heart failure, and dysphagia, had a Foley catheter inserted, but there was no physician order for the catheter in the resident's clinical record. This was confirmed by an LPN during an interview. The absence of a physician order for the catheter indicates a failure to follow the facility's medication and treatment order policy, which mandates that all treatments must be consistent with safe and effective order writing.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions of respiratory equipment for a resident, identified as Resident R51. The facility's policy on oxygen administration requires that the humidifying jar on the oxygen concentrator contains water and that the water level is sufficient for bubbling as oxygen flows. Additionally, the policy for administering medications through a nebulizer mandates that the equipment be rinsed, disinfected, and stored in a labeled plastic bag after use. However, during an observation, it was noted that the nebulization machine for Resident R51 was not stored in a bag, nor was it labeled with the date. Furthermore, the humidifying jar on the oxygen concentrator was found to be void of water. Resident R51, who has diagnoses of anemia, hypertension, and chronic bronchitis, was observed in bed with the nebulization machine improperly stored and the oxygen concentrator's humidifying jar empty. The resident's physician orders included the use of Ipratropium-Albuterol Solution for nebulization every four hours as needed and oxygen at two liters per minute via nasal cannula, with a directive to change the oxygen tubing and canister weekly. An LPN confirmed the deficiencies in the storage and labeling of the nebulizer equipment and the lack of water in the humidifying jar, indicating a failure to adhere to the facility's respiratory care policies.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to two residents diagnosed with Post Traumatic Stress Disorder (PTSD). The facility's policy on Trauma Informed Care, dated 8/1/24, outlines the importance of recognizing and responding to trauma to avoid re-traumatization. However, the care plans for both residents did not identify specific PTSD triggers or strategies to avoid them, which is a critical component of trauma-informed care. Resident R36, who was admitted to the facility with diagnoses including PTSD, high blood pressure, and chronic pain, had a care plan that acknowledged the PTSD diagnosis but did not specify the triggers or how to mitigate them. Similarly, Resident R84, admitted with PTSD, muscle weakness, and difficulty walking, also had a care plan lacking identification of PTSD triggers. The Social Service Director confirmed the facility's failure to identify and address these triggers, which is necessary to prevent re-traumatization.
Failure to Conduct Ongoing Bed Rail Assessments
Penalty
Summary
The facility failed to conduct ongoing assessments to ensure that bed rails were used appropriately to meet the needs of two residents, R51 and R79, and to evaluate the risks associated with their usage. According to Title 42 CFR S483.25(n), facilities must assess residents for the risk of entrapment from bed rails before installation and perform ongoing evaluations. However, the facility did not adhere to these regulations. For Resident R51, who was admitted with conditions such as anemia, hypertension, and chronic bronchitis, the last documented evaluation of the assist rails was on 3/12/24, despite the facility's policy requiring quarterly, annual, and condition-change evaluations. The Director of Nursing confirmed the lack of ongoing assessments for this resident. Similarly, Resident R79, diagnosed with parkinsonism, diabetes, and an overactive bladder, had enabler bars ordered for positioning and participation in care. The most recent evaluation for these assist rails was also dated 3/12/24. The Nursing Home Administrator confirmed that the facility did not conduct the necessary ongoing assessments for this resident. These findings indicate a failure to comply with both federal regulations and the facility's own policies regarding the use of bed rails, potentially compromising resident safety.
Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to store medications and biologicals properly and securely in one of its medication carts. During an observation, it was found that the medication cart contained several items that were not labeled with the date they were opened, including a vial of artificial tears, a vial of fluticasone nasal spray, a bottle of lactulose solution, and an Anora Ellipta inhaler. Additionally, the cart contained personal items such as an opened bottle of pure leaf tea and two cans of Arizona herbal tonic energy drink. A medicine cup labeled with the initial 'H' was also found, containing various tablets and capsules. A Registered Nurse (RN) confirmed these observations and stated that the medicine cup belonged to a resident who was sleeping, and the drinks were personal items.
Infection Control Deficiencies During COVID-19 Outbreak and Dressing Change
Penalty
Summary
The facility failed to implement proper infection control measures during a COVID-19 outbreak, specifically for Resident R6. Despite the facility's policy requiring immediate testing for COVID-19 symptoms, Resident R6, who had symptoms such as a headache and sore throat after a leave of absence, was not tested promptly. The resident was eventually tested and found positive for COVID-19, but the facility did not follow its own guidelines for outbreak management, including the lack of signage indicating an active outbreak and inconsistent testing protocols. Additionally, the facility did not adhere to infection control practices during a dressing change for Resident R13. The LPN involved in the procedure failed to establish a clean field, used a washable lift pad improperly, and did not maintain sterile technique. The LPN also placed contaminated items on the floor and returned used supplies to the medication cart, which could lead to cross-contamination. These deficiencies highlight lapses in the facility's adherence to its infection prevention and control policies, as confirmed by interviews with staff members, including the Infection Preventionist and the Nursing Home Administrator. The failure to implement these measures compromised the facility's ability to manage infections effectively and prevent cross-contamination during medical procedures.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two residents. The facility's policy requires that a written notice of transfer or discharge be sent to the resident or their representative, including a copy to the Ombudsman. However, for Resident R1, who was admitted with vascular dementia, urinary tract infection, and hypertension, and transferred to the hospital, there was no documented evidence of such notification. Similarly, Resident R9, admitted with end-stage renal disease, anemia, and diabetes, was also transferred to the hospital without the required notification to the Ombudsman. Interviews with facility staff revealed a lack of awareness regarding the requirement to notify the Ombudsman. The Social Service Director admitted to not notifying the Ombudsman of hospital transfers, stating unawareness of the necessity. The Director of Nursing confirmed that the facility did not send any notifications to the Ombudsman's Office, acknowledging the failure to comply with the notification requirement for the two residents. This deficiency was identified under 28 Pa. Code 201.29 (a) (c.3) (2) concerning resident rights.
Failure to Readmit Hospitalized Resident Without Proper Notification
Penalty
Summary
The facility failed to permit the readmission of a hospitalized resident, identified as Resident R1, without providing evidence that the facility was unable to meet the resident's needs. Resident R1, who was admitted with diagnoses including Vascular Dementia with agitation, Urinary Tract Infection, and Hypertension, exhibited increased behaviors such as exit-seeking and aggression towards staff. Despite these behaviors, there was no documentation indicating that the family or resident was informed of the need for a secure unit or transfer to another facility, nor was there a formal notice of discharge provided. Interviews with facility staff, including the Admission Coordinator and Social Service Director, revealed that the decision not to readmit Resident R1 was based on the resident's behaviors and the need for a locked-down unit. However, the Nursing Home Administrator confirmed that no formal discharge notice was given to the family, and the hospital was informed that the facility would not be taking Resident R1 back. This lack of communication and documentation led to the deficiency, as the facility did not follow proper procedures for transfer and discharge, failing to provide necessary notifications and evidence of inability to meet the resident's needs.
Insufficient Staffing Leads to Delayed Care and Hygiene Issues
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of eight out of twelve residents, as evidenced by resident interviews and observations. Residents reported long wait times for call light responses, with some waiting over an hour for assistance. Several residents were observed in nightgowns or hospital gowns, indicating they had not been assisted with personal hygiene or dressing. Additionally, residents expressed dissatisfaction with the frequency of showers, with some receiving only one shower per week or having showers scheduled during inconvenient hours. The facility's policy on answering call lights, dated 7/13/23, was not adhered to, as residents experienced delays in receiving care. Observations revealed residents with unkempt or greasy hair, and shower records indicated missed or undocumented showers. Residents also reported that staff often promised to return to assist them but failed to do so. The Nursing Home Administrator confirmed the facility's failure to provide sufficient staffing to meet the needs of the residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 695 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beaver Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Providence Health & Rehab Center | 6 mi | ★★★★★ | 44 | 1 |
| Friendship Rehab And Health | 6.6 mi | ★★★★★ | 53 | 1 |
| Rochester Residence And Care Center | 9.1 mi | — | 109 | 2 |
| Covington Skilled Nursing & Rehab Center | 9.3 mi | ★★★★★ | 0 | 0 |
| Calcutta Health Care Center | 10.1 mi | ★★★★★ | 2 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Beaver Valley Rehabilitation And Healthcare Center.
100% money-back within 48 hours.
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.