Beaver Valley Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Beaver Valley Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 3, 2023

  Based on review of facility documentation, clinical record, and staff interview it was determined that the facility failed to implement measures and plan of care, provide adequate supervision and effective safety measures to prevent elopement (unauthorized leave from a safe area) of a resident with wandering behaviors and history of elopement behaviors. This enabled the resident to open a door which alarmed for 15 sec prior to unlocking and allowing access to an unsupervised stairwell which resulted in a fall down the stairs, resulting in an immediate jeopardy situation for one of three residents reviewed (Resident R1). Resident R1 sustained a head injury and was sent to a local hospital and then required further treatment at a Trauma Center of two staples for a laceration. […]

• Actual harm, isolatedF656Oct 19, 2021

  Based on facility policy and clinical record review, and staff interview, it was determined that the facility failed to develop a comprehensive care plan to prevent new pressure injury (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development associated with use of an orthopedic brace (immobilizer), which resulted in harm in the development of a pressure ulcer for one of one residents (Resident R99). Findings include: A review of the facility policy Initial Care Plan Completion and Ongoing Care Plan Updates dated 7/8/21, indicated the facility will follow a uniform process for initiating the care plan upon admission and ensure that care plans are updated. Staff will update the care plans related to the physician orders and/or changes in care needs. […]

• Actual harm, isolatedF686Oct 19, 2021

  Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to timely provide adequate preventative treatment and services to prevent new pressure injury (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development associated with use of an orthopedic brace (immobilizer), which resulted in harm in the development of a pressure ulcer for one of four residents (Resident R99) reviewed. Findings include: A review of the facility policy Prevention of Pressure Ulcers/Injuries dated 7/8/21, indicated residents will be assessed for risk factors weekly to include areas of impaired circulation due to pressure from positioning or medical devices. […]

• No harm, potential for more than minimal, widespreadF812Aug 14, 2026

  Based on a review of facility policies, observations, and staff interviews it was determined that the facility failed to properly date, and store food products, and failed to verify the chemical sanitation of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for food borne illness.Findings Include: Review of the facility policy Food Receiving and Storage dated 12/22/25, indicated that foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer are covered, labeled, and dated. […]

• No harm, potential for more than minimal, widespreadF880Dec 1, 2025

  Based 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… […]