Pennsylvania Department of Health
BEAVER VALLEY HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BEAVER VALLEY HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are 173 surveys for this facility. Please select a date to view the survey results.

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BEAVER VALLEY HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to a complaint, completed on May 20, 2025, it was determined that Beaver Valley Healthcare and Rehabilitation was in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; however, the facility was not in compliance with the 28. Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of staffing documents provided by the facility and staff interview it was determined that the facility administrative staff failed to provide one nurse assistant (NA) per 10 residents on the daylight shift for 9 of 21 days (4/28/25, 4/29/25, 5/1/25, 5/3/25, 5/4/25, 5/5/25, 5/8/25, 5/9/25, 5/11/25) , one NA per 11 residents on the second shift for 13 of 21 days (4/27/25, 4/28/25, 4/30/25, 5/1/25, 5/4/25, 5/5/25, 5/8/25, 5/11/25, 5/12/25, 5/14/25, 5/15/25, 5/16/25, 5/17/25) and one NA per 15 residents on the night shift on 12 of 21 days (4/27/25, 5/2/25, 5/3/25, 5/4/25, 5/5/25, 5/7/25, 5/9/25, 5/11/25, 5/12/25, 5/13/25, 5/14/25, 5/17/25) as required.

Review of facility census data and nursing time schedules from 4/27/25, through 5/17/25, revealed the following nurse assistant (NA) staffing shortages:

Day shift:
Date: Census: Actual hours: Hours required:
4/28/25 105 75.00 84.00
4/29/25 105 80.00 84.00
5/1/25 105 80.00 84.00
5/3/25 99 72.00 79.20
5/4/25 97 64.00 77.60
5/5/25 97 66.00 77.60
5/8/25 97 72.00 77.60
5/9/25 96 64.00 76.80
5/11/25 95 71.00 76.00

Evening shift:
Date: Census: Actual hours: Hours required:
4/27/25 105 75.00 84.00
4/28/25 105 72.00 76.36
4/30/25 107 77.00 77.82
5/1/25 105 68.00 76.36
5/4/25 97 68.00 70.55
5/5/25 97 69.50 70.55
5/8/25 98 68.00 71.27
5/11/25 93 64.00 67.64
5/12/25 91 58.00 66.18
5/14/25 95 56.00 60.09
5/15/25 95 62.00 69.09
5/16/25 95 64.00 69.09
5/17/25 94 68.00 68.36

Night Shift:
Date: Census: Actual hours: Hours required:
4/27/25 105 48.00 56.00
5/2/25 99 48.00 52.80
5/3/25 99 48.00 52.80
5/4/25 97 48.00 51.73
5/5/25 97 48.00 51.73
5/7/25 96 49.00 51.20
5/9/25 95 48.00 50.67
5/11/25 93 48.00 49.60
5/12/25 91 48.00 48.53
5/13/25 94 48.00 50.13
5/14/25 95 48.00 50.67
5/17/25 94 48.00 50.13

During an interview completed on 5/20/25, at 12:07 p.m. the Director of Nursing confirmed the facility administrative staff failed to provide one nurse assistant (NA) per 10 residents on the daylight shift for 9 of 21 days (4/28/25, 4/29/25, 5/1/25, 5/3/25, 5/4/25, 5/5/25, 5/8/25, 5/9/25, 5/11/25) , one NA per 11 residents on the second shift for 13 of 21 days (4/27/25, 4/28/25, 4/30/25, 5/1/25, 5/4/25, 5/5/25, 5/8/25, 5/11/25, 5/12/25, 5/14/25, 5/15/25, 5/16/25, 5/17/25) and one NA per 15 residents on the night shift on 12 of 21 days (4/27/25, 5/2/25, 5/3/25, 5/4/25, 5/5/2, 5/7/25, 5/9/25, 5/11/25, 5/12/25, 5/13/25, 5/14/25, 5/17/25) as required.

Plan of Correction - To be completed: 06/09/2025

The facility will continue to take steps 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, Assistant Director of Nursing, and scheduling coordinator.

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.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one Licensed Practical Nurse (LPN) per 40 residents on night shift for 6 of 21 days (5/2/25,5/5/25, 5/10/25, 5/14/25, 5/15/25, 5/16/25) as required.

Findings include:

Review of facility census data and nursing time schedules from 4/27/25, through 5/17/25, revealed the following Licensed Practical Nurse (LPN) staffing shortages:

Night Shift:
Date: Census: Actual hours: Hours required:
5/2/25 99 8.0 19.80
5/5/25 97 12.00 19.40
5/10/25 95 16.00 19.00
5/14/25 95 16.00 19.00
5/15/25 95 16.00 19.00
5/16/25 95 8.0 19.00

During an interview completed on 5/20/25, at 12:07 p.m. the Director of Nursing confirmed the facility administrative staff failed to provide a minimum of one Licensed Practical Nurse (LPN) per 40 residents on night shift for 6 of 21 days (5/2/25,5/5/25, 5/10/25, 5/14/25, 5/15/25, 5/16/25) as required.

Plan of Correction - To be completed: 06/09/2025

The facility will continue to take steps to adequately staff licensed practical nurses (LPN) to meeting staffing requirements

The Nursing Home Administrator or designee will conduct a daily labor meeting and audit the LPN schedule to ensure the LPN 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 LPN 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 LPN's to meet the facility needs.

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