Health inspection·March 26, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, closed resident clinical records, facility documents, staff interviews, it was determined that the facility failed to report an allegation of sexual abuse for one of five sampled residents (Closed Resident Record CR1). Findings include: The facility Abuse investigation and reporting policy last reviewed on 8/1/24, indicated that all reports of resident abuse, neglect , exploitation, and misappropriation of resident property shall be promptly reported to the local, state and federal agencies and thoroughly investigated by facility management. If an incident or suspected incident of resident abuse is reported, Administration will assign the investigation to an appropriate individual. The Administrator will provide any supporting documentation, will keep the resident or resident representative informed, and will ensure any further abuse is prevented. The assigned investigator will record the results of the investigation. An alleged violation of abuse will be reported. Review of Closed Resident Record CR1's admission record indicated she was admitted on [DATE]. Review of Closed Resident Record CR1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 12/3/24, indicated that she had diagnoses that included an injury to the right achilles tendon, diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), hypothyroidism (decrease in production of thyroid hormone), and congestive heart failure (a progressive heart disease affecting pumping action of the heart muscles impacting circulation, swelling and shortness of breath). These were the most recent diagnoses upon review. Review of Closed Resident Record CR1's care plan dated 1/6/25, indicated to observed for changes in mood. Review of Closed Resident Record CR1's CRNP clinical progress note dated 1/9/25, indicated the following: earlier this week, another male resident with dementia reportedly entered her room and fondled her breast. She was very upset and she denied physical injury, or breast pain. Incident being investigated by Administration. Review of Closed Resident Record CR1's clinical nurse progress notes, social services notes, or additional physician documents did not include any evidence of an abuse investigation or abuse report. Page 1 of 4 395266 395266 03/26/2025 Beaver Valley Rehabilitation and Healthcare Center 257 Georgetown Road Beaver Falls, PA 15010

F 0609 The facility abuse investigation documents, from December 2024 to March 2025, did not include: Level of Harm - Minimal harm or potential for actual harm -a report to the local State field office about Closed Resident Record CR1's allegation -a notification to the local police department Residents Affected - Few -a notification to the Department of Aging During an interview on 3/26/25, at 10:27 a.m. the Certified Registered Nurse Practitioner (CRNP) Employee E1 stated the following: Closed Resident Record CR1 claimed another resident came into her room and touched her breast area. She spoke to Administration and nursing administration was aware and investigating it further. During an interview on 3/26/25, at 11:18 a.m. the Facility social worker Employee E2 stated the following: Closed Resident Record CR1 did discuss being touched with one of the nurses and the administrator. She did not go into full detail. I let her know she could speak with me. I believe I put a note in. If an allegation turns into a reportable incident, the DON or administrator work on that. During an interview on 3/26/25, at 12:35 p.m. information disseminated to the Director of Nursing (DON) that the facility failed to report an allegation of sexual abuse for Closed Resident Record CR1 as required. 28 Pa Code: 201.14 (a)(c )(e) Responsibility of management. 28 Pa Code: 201.18 (b)(1)(e)(1) Management. 395266 Page 2 of 4 395266 03/26/2025 Beaver Valley Rehabilitation and Healthcare Center 257 Georgetown Road Beaver Falls, PA 15010

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, closed clinical records and staff interviews, it was determined that the facility failed to make certain allegations of abuse are thoroughly investigated for one of five sampled residents (Closed Resident Record CR1). Residents Affected - Few Findings include: The facility Abuse investigation and reporting policy last reviewed on 8/1/24, indicated that all reports of resident abuse, neglect , exploitation, and misappropriation of resident property shall be promptly reported to the local, state and federal agencies and thoroughly investigated by facility management. If an incident or suspected incident of resident abuse is reported, Administration will assign the investigation to an appropriate individual. The Administrator will provide any supporting documentation, will keep the resident or resident representative informed, and will ensure any further abuse is prevented. The assigned investigator will record the results of the investigation. An alleged violation of abuse will be reported. Review of Closed Resident Record CR1's admission record indicated she was admitted on [DATE]. Review of Closed Resident Record CR1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 12/3/24, indicated that she had diagnoses that included an injury to the right achilles tendon, diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), hypothyroidism (decrease in production of thyroid hormone), and congestive heart failure (a progressive heart disease affecting pumping action of the heart muscles impacting circulation, swelling and shortness of breath). These were the most recent diagnoses upon review. Review of Closed Resident Record CR1's care plan dated 1/6/25, indicated to observed for changes in mood. Review of Closed Resident Record CR1's CRNP clinical progress note dated 1/9/25, indicated the following: earlier this week, another male resident with dementia reportedly entered her room and fondled her breast, she was very upset and she denied physical injury, or breast pain. Incident being investigated by Administration. Review of Closed Resident Record CR1's clinical nurse progress notes, social services notes, or additional physician documents did not include any evidence of an abuse investigation or abuse report. The facility abuse investigation documents, from December 2024 to March 2025, did not include: -a signed statement from Closed Resident Record CR1 about this allegation -identifying the other resident that touched Closed Resident Record CR1 -signed statements from facility staff -actions to prevent re-occurrence with this and other residents 395266 Page 3 of 4 395266 03/26/2025 Beaver Valley Rehabilitation and Healthcare Center 257 Georgetown Road Beaver Falls, PA 15010

F 0610 -specific actions to ensure resident safety Level of Harm - Minimal harm or potential for actual harm -interviews with additional residents to ensure their safety -assessment of the other resident to determine root cause Residents Affected - Few During an interview on 3/26/25, at 10:27 a.m. the Certified Registered Nurse Practitioner (CRNP) Employee E1 stated the following: Closed Resident Record CR1 claimed another resident came into her room and touched her breast area. She spoke to Administration and nursing administration was aware and investigating it further. During an interview on 3/26/25, at 11:18 a.m. the Facility social worker Employee E2 stated the following: Closed Resident Record CR1 did discuss being touched with one of the nurses and the administrator. She did not go into full detail. I let her know she could speak with me. I believe I put a note in. If an allegation turns into a reportable incident, the DON or administrator work on that. During an interview on 3/26/25, at 12:35 p.m. information disseminated to the Director of Nursing (DON) that the facility failed to make certain allegations of abuse are thoroughly investigated for Closed Resident Record CR1 as required. 28 Pa. Code: 201.14 (a)(c)(e) Responsibility of licensee. 28 Pa. Code: 201.18 (e) (1) Management. 28 Pa. Code: 201.20 (b) Staff development. 395266 Page 4 of 4