Meadow View Nursing Center

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that there was a physician's order for oxygen therapy for two of 40 residents reviewed (Residents 2, 24).Findings include: The facility's policy for oxygen use, dated January 19, 2026, revealed that residents who required oxygen would have a physician's order which included the oxygen flow rate, how the oxygen would be administered (i.e. nasal cannula or mask), if humidified air was required, and how often the oxygen tubing should be changed.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 9, 2025, revealed that the resident was cognitively intact, used oxygen, and had diagnoses that included pulmonary embolism (blood clot that goes to lungs). Nursing notes, dated November 7 at 10:46 a.m., November 10 at 11:14 a.m., November 12 at 10:35 p.m., November 15 at 11:02 a.m., and November 16, 2025, at 10:17 a.m., revealed the resident was using 3 liters per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a performance review of every nurse aide at least once every 12 months for one of three nurse aides reviewed (Nurse Aide 2). Findings include:The facility's policy regarding performance evaluations, dated January 19, 2026, indicated that performance evaluations were to be completed for all employees annually.A review of the annual performance evaluation for Nurse Aide 2 revealed the evaluation was completed on September 21, 2024. As of February 5, 2026, there was no documented evidence that an annual performance evaluation had been completed since September 21, 2024. Interview with the Nursing Home Administrator on February 5, 2026, at 12:36 p.m. confirmed that the annual performance evaluation was not completed as required for Nurse Aide 2.28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' bathrooms for three of seven residents reviewed (Residents 3, 4, 6). Findings included: The facility's policy regarding cleaning and disinfecting, dated September 1, 2024, indicated that the facility was to provide a sanitary and homelike environment. Observations of Resident 4's bathroom on April 23, 2025, at 11:25 a.m. revealed that the base of the toilet, where the toilet and the floor meet, had a heavy accumulation of dried, yellowish/brown, removable debris. This debris was noted to encompass all sides of the toilet base. Observations of Resident 3's bathroom on April 23, 2025, at 11:57 a.m. revealed that the entire base of the toilet had an accumulation of dried, crusted, yellowish debris, with pieces of caulking coming off. Interview with the Maintenance Director on April 23, 2025, at 12:05 p.m. confirmed that the floor around the toilet bases in Residents 3's and 4's bathroom were in need of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for nine of 43 residents reviewed (Residents 3, 9, 12, 18, 45, 58, 85, 88, 131). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the intent of Section N was to record the number of days, during the seven days of the assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Sections N0145B antianxiety, N0415F Antibiotic, N0415G Diuretic, N0415H Opioid (narcotic medications used to treat pain), and N0415K anticonvulsant medications were to be coded if the resident took the medication during the seven-day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect specific care needs for three of 43 residents reviewed (Residents 8, 26, 42). Findings include: A facility policy for care plans, dated September 12, 2024, indicated that care plans will be reviewed and revised as necessary by the interdisciplinary team at least quarterly after each Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) or more often as changes occur. An annual MDS assessment for Resident 8, dated December 21, 2024, indicated that the resident was cognitively impaired, required assistance with care needs, used oxygen, and had a diagnosis of hemiplegia and hemiparesis (paralysis or weakness to one side of the body due to brain injury). A respiratory care plan for Resident 8, dated December 19, 2024, indicated that the resident was to be provided oxygen as ordered. A nursing note for Resident 8, dated January 25, 2025, at 3:54 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Pennsylvania's Nursing Practice Act, facility policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to correctly transcribe physician's orders for one of 43 residents reviewed (Resident 9), and failed to ensure that a licensed practical nurse followed professional standards regarding the administration of medications for one of 43 residents reviewed (Resident 81). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 9, dated January…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice by failing to follow physician's orders for two of 43 residents reviewed (Residents 10, 57). Findings include: The facility's policy regarding medication administration, dated September 12, 2024, revealed that medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dose, right time, and method (route) of administration before giving the medication. Physician's orders for Resident 10, dated December 22, 2024, included an order for the resident to receive one 10 milligram (mg) tablet of Midodrine (used to treat low blood pressure (hypotension) three times a day for hypotension, and staff was to hold the medication if the resident's systolic blood pressure (the top number of the blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to flush a PICC line (a tube placed in a vein that can be used to deliver fluids and/or medications) and a peripheral intravenous catheter (a small, thin tube inserted into a vein in the arm, hand or foot to administer medications and/or fluids) as ordered by the physician for two of 43 residents reviewed (Residents 8, 117), failed to administer intravenous fluids as ordered by the physician for one of 43 residents reviewed (Resident 8), and failed to change PICC line dressing as ordered by the physician for one of 43 residents reviewed (Resident 122). Findings include: The facility's policy regarding PICC line dressing changes, dated September 12, 2024, indicated that the PICC's will be flushed every shift and after each use with five to 10 cubic centimeters (cc) of normal sterile saline (NSS - a mixture of water and salt with a salt concentration of 0.9 percent) and five cc of Heparin (used to prevent and treat blood clots) if the physician's orders indicate.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed, resulting in significant medication errors for one of 43 residents reviewed (Resident 3), and failed to ensure that residents were free from significant medication errors for one of 43 residents reviewed (Resident 81). Findings include: The facility's policy regarding medication administration, dated September 12, 2024, revealed that medications must be administered in accordance with the orders, including any required time frame. The individual administering medications must check the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: checking identification band, checking photograph attached to the medical record, and if necessary, verify resident identification with other facility personnel. The individual administering the medication must check the label…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for three of 43 residents reviewed (Residents 45, 117, 122). Findings include: A significant Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated November 25, 2024, revealed that the resident was cognitively intact, required assistance from staff for her daily care needs, required oxygen therapy, and had diagnoses that included atrial fibrillation (irregular heartbeat), high blood pressure, right femur fracture, asthma, and chronic obstructive pulmonary disease. Review of nurse aide documentation of care for Resident 45, dated December 2024 and January 2025, revealed that the resident was to be showered each Monday and Friday evening. Documentation for Resident 45 for December 2, 9, 13, 16, 20, 23, 27,30, 2024, and January 3, 6, 10, 13, 17, 20, 24 and 31, 2025, indicated not applicable for showers/bath. There was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for three of 43 hospice residents reviewed (Residents 18, 57, 93). Findings include: The facility's policy regarding Hospice services (a type of end-of-life care that includes physical, emotional, and spiritual support for people with terminal illnesses), dated September 12, 2024, revealed that Hospice will provide the skilled nursing facility within 48 to 72 hours of admission the following: A copy of the physician's certification of terminal illness (a form signed by the resident's hospice physician and specific to each patient); a copy of the Hospice agreement signed by the resident/resident's legal representative; and a copy of the Hospice coordinated plan of care. The Hospice documents will be a part of the resident's medical record and filed either on the chart or in a separate folder, which remains with the chart.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending March 7, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending February 7, 2025, identified repeated deficiencies related to a failure to complete accurate Minimum Data Set (MDS) assessments (mandated assessment of a resident's abilities and care needs); failure to update residents' care plans; failure to provide professional nursing services; failure to provide quality care; failure to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for four of 43 residents reviewed (Residents 10, 27, 65, 93). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP's) are an infection control intervention designed to reduce transmission of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative in writing of the transfer and reason for hospitalization for three of 43 residents reviewed (Residents 3, 45, 93). This deficiency was cited as past noncompliance. Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 29, 2024, indicated that the resident had moderate cognitive impairment, required assistance from staff for personal care needs, and had diagnoses that included a displaced trimalleolar fracture of the left lower leg (fracture in the ankle joint on the left leg). A physician's note for Resident 3, dated November 19, 2024, at 5:17 p.m., revealed that the resident had fallen in her room and had an obvious left ankle deformity. She was transferred to the emergency room for evaluation and treatment. There was no documented evidence that a written notice of Resident 3's transfer to the hospital was provided to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident and/or the resident's representative at the time of a transfer for three of 43 residents reviewed (Residents 3, 45, 93). This deficiency was cited as past noncompliance. Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 29, 2024, indicated that the resident had moderate cognitive impairment, required assistance from staff for personal care needs, and had diagnosis that included a displaced trimalleolar fracture of the left lower leg (fracture in the ankle joint on the left leg). A physician's order note for Resident 3, dated November 19, 2024, at 5:17 p.m., revealed that the resident had fallen in her room and had an obvious left ankle deformity. She was transferred to the emergency room for evaluation and treatment. There was no documented evidence that a bed-hold…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that comprehensive resident-centered care plans were developed and implemented for one of 43 residents reviewed (Resident 45). Findings include: The facility's policy regarding care plans, dated September 12, 2024, indicated that the facility will create a person-centered care plan including necessary and appropriate care, attending physician orders, services and accommodation of resident needs and preferences in order for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated November 25, 2024, revealed that the resident was cognitively intact, required assistance from staff for her daily care needs, required oxygen therapy, and had diagnoses that included atrial fibrillation (irregular heartbeat), high blood pressure, right femur…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent accidents or injury were in place for one of 43 residents reviewed (Resident 88). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 88, dated January 7, 2025, revealed that the resident was cognitively impaired, was dependent on staff for daily care needs, and had diagnoses that included dementia. Review of Resident 88's care plan, dated October 4, 2024, indicated that the resident was at risk for falling. An intervention, dated October 22, 2024, indicated that the resident was to wear hipsters when out of bed. Review of a nurse's note for Resident 88, dated November 9, 2024, at 9:34 p.m., revealed that the resident was observed lying on the floor in the solarium on B hall and he was not wearing hipsters. Review of a nurse's note for Resident 88, dated January 31, 2025, at 4:12 p.m., revealed that the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for one of three nurse aides reviewed (Nurse Aide 4). Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 4 was due by April 8, 2024. However, there was no documented evidence that an annual performance evaluation was completed between March 15, 2023, and January 15, 2025, as required for this nurse aide. Interview with the Nursing Home Administrator on February 7, 2025, at 11:09 a.m. confirmed that an annual performance evaluation was not completed as required for Nurse Aide 4. 28 Pa. Code 201.18(e)(1) Management.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of 43 residents reviewed (Resident 80). Findings include: Physician's orders for Resident 80, dated July 16, 2024, included an order for the resident to receive one 50 milligram (mg) tablet of Tramadol (a narcotic medication to treat moderate to severe pain) every six hours as needed for moderate to severe pain. Resident 80's controlled drug logs for December 2024 and January 2025 revealed that staff signed out doses of Tramadol for administration to the resident on December 9, 2024, at 9:00 a.m.; December 20, 2024, at 9:00 a.m.; December 23, 2024, at 9:00 a.m.; December 29, 2024, at 9:00 a.m.; January 11, 2025, at 8:30 p.m.; January 12, 2025, at 9:00 a.m.; and on January 16, 2025, at 9:40 a.m. However, the resident's clinical record, including the Medication Administration Records (MARs) and the nursing notes, revealed no documented evidence that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of facility policies, manufacturer's instructions, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to securely store medication for one of 43 residents reviewed (Resident 57), and failed to label multi-dose containers of medications with the date they were opened in one of three medication carts observed (Third floor medication cart). Findings include: The facility's policy regarding medication administration, dated September 12, 2024, revealed that residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of the resident's abilities and care needs) for Resident 57, dated December 17, 2024, revealed that the resident was understood and could understand others. A care plan for the resident, dated April 9, 2024, revealed that the resident was on diuretic therapy (medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for seven of 41 residents reviewed (Residents 1, 49, 68, 87, 90, 122, 124). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that if the pneumococcal (pneumonia) vaccine was not received, Section O0300C (pneumococcal vaccine) was to be coded with the reason the pneumonia vaccine was not received. The section was to be coded with a one (1) if the resident was not eligible (medical contraindication); two (2) if the vaccine was offered and declined; or (3) if the vaccine was not offered. A quarterly MDS assessment for Resident 1, dated January 5, 2024 revealed that Section O0300B was coded with not assessed, no information. However, a pneumococcal consent/declination form,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify physician's orders for pain management for one of 41 residents reviewed (Resident 19). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. Physician's orders for Resident 19, dated January 17, 2024, included an order for the resident to receive one 10-325 milligrams (mg) tablet of Norco (a narcotic pain medication) every six hours for moderate to severe pain (4-10) (on a scale of 0 to 10 where 10 is the worst pain). The order did not include instructions for the staff to give the Norco when the resident's pain rating was 0 to 3,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a tube feeding was administered in accordance with the facility's policy for one of 41 residents reviewed (Resident 122). Findings include: The facility's policy regarding enteral feeding (nutritional formula provided via a tube inserted into the stomach), dated October 6, 2023, indicated that nursing staff will check and document for residual volume prior to administering the feeding. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 122, dated January 25, 2024, indicated that the resident was cognitively intact, required minimal assistance from staff for all daily care needs, and had a feeding tube (a tube surgically implanted into the stomach for feeding). Review of Resident 122's clinical record from January 18, 2024, through March 4, 2024, revealed that there was no documented evidence that gastric residuals were checked prior to administering tube feedings per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of anti-anxiety medications for one of 41 residents reviewed (Resident 79). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 79, dated December 27, 2023, indicated that the resident was cognitively impaired, received antianxiety medication, and had diagnoses that included dementia. Physician's orders, dated December 17, 2023, included an order for the resident to receive 0.5 milligrams/milliliter (mg/mL) of lorazepam (an antianxiety medication) gel applied to the inner wrist topically every eight hours as needed for anxiety, and physician's orders, dated January 18, 2024, included orders for the resident to receive 0.5 mg of Ativan (an antianxiety medication) every eight hours as needed for anxiety. Physician's orders, dated February 1, 2024, included orders for the resident to receive 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Findings include: The facility's current policy regarding food temperatures and resident tray audits, dated October 6, 2023, indicated that the facility's standards for test tray temperatures were to be 135 degrees Fahrenheit (F) or higher for soups, hot cereals, eggs, pancakes/waffles/French toast, entree/casseroles, starches, and vegetables; 120 to 160 degrees F for hot beverages; and 41 degrees F and lower for salads, desserts, fruit, juice, and milk. Interview with Resident 12 on March 4, 2024, at 12:51 p.m. revealed that he does not like the taste of the food. Interview with Resident 45 on March 4, 2024, at 11:45 a.m. revealed that the French fries she receives are cold, and that she threw up when she had the liver and onions. Observations in the main kitchen on March 6, 2024, revealed that the Second Floor second cart left the main kitchen at 11:39 a.m. and arrived on the Second Floor at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to ensure that food was served under sanitary conditions, and failing to ensure that ice was made and stored in sanitary ice machines for one of four ice machines (Second Floor Nourishment Station). Findings include: Observations in the walk-in freezer on March 4, 2024, at 9:09 a.m. and March 6, 2024, at 11:05 a.m. revealed that there was an accumulation of ice on the ceiling, the floor, and metal storage racks, as well as on cases of asparagus cuts and tips, fresh frozen brussel sprouts, and breaded popcorn shrimp that were stored on the shelves below the freezer condenser. Interview with the Registered Dietitian on March 6, 2024, at 11:05 a.m. confirmed that there was an accumulation of ice on the food products stored below the freezer condensers in the walk-in freezer. Review of the main kitchen's daily floor cleaning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) surveys ending April 13, 2023, and July 27, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending March 7, 2024, identified repeated deficiencies related to freedom from abuse/neglect, accuracy of Minimum Data Sets (MDS) assessments, services provided to meet professional standards, quality of care, safety and accidents hazards, palatability of food, food procurement/storage/preparation, and infection control. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of guidance from the Pennsylvania Department of Health (DOH) and review of the facility's policies, as well as observations and staff interviews, it was determined that the facility failed to follow infection control standards and DOH guidelines to reduce the spread of infections and prevent cross-contamination. Findings include: Pennsylvania Department of Health, COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care (LTC), dated February 2024, revealed that personal protective equipment (PPE) is a key component of infection prevention practices in LTCF's. PPE is equipment that is worn to minimize exposure to hazards that may cause workplace harm or illness. In LTCF's and other medical settings, health care professionals (HCP) are to wear PPE to protect them from potentially infectious conditions. This includes equipment such as respirators, masks, gowns, gloves, and eye protection. While having the recommended PPE is important to protect the wearer, it is equally critical to ensure the wearer knows how to appropriately don (put on) and doff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for two of 41 residents reviewed (Residents 88, 115). Findings include: The facility's abuse policy, dated October 6, 2023, indicated that each resident had the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and exploitation. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 88, dated January 9, 2024, indicated that the resident was cognitively intact and required assistance from staff for all his care needs. Resident 88's care plan, dated December 21, 2023, indicated that the resident was dependent on staff for all activities of daily living. Facility documents, undated, revealed that Nurse Aide 1 completed the nurse aide training program on December 22, 2023, and that he received education on abuse, resident rights, and resident psychosocial needs in the nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow its abuse policy regarding the immediate release of an involved staff member from their duty pending a full investigation, to protect the resident/victim for two of 41 residents reviewed (Residents 88, 115) and to implement its abuse prohibition policies regarding verifying new employees' standing with the Pennsylvania Nurse Aide Registry or the State Board of Nursing for two of five new employees reviewed (Nurse Aide 11, Registered Nurse 12). Findings include: The facility's policy regarding abuse, dated October 6, 2023, indicated that every complaint or allegation of resident abuse or neglect shall be promptly reported to the immediate supervisor of the area, and the Nursing Home Administrator and/or his/her designee. Each report shall be treated promptly and with discretion, with the following priorities of concern: protection of the person and rights of the resident (alleged victim); compliance with pertinent laws and regulations; protection of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to revise resident care plans with individualized interventions to address their care needs for one of 41 residents reviewed (Resident 49). Findings include: A facility policy for pacemakers (a small, battery-powered device that prevents the heart from beating too slowly), dated October 6, 2023, revealed that the facility will place the physician's orders for pacemaker monitoring on the resident's care plan. An admissions Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 49, dated February 19, 2024, revealed that the resident was understood and could understand others, was cognitively intact, required maximum assistance with dressing and toilet use, and had diagnoses of coronary artery disease and heart failure. The current care plan for Resident 49 revealed that he had a pacemaker; however, there was no documented evidence of an appointment for pacemaker monitoring. Interview with the Registered Nurse Assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide medications as ordered by the physician for one of 41 residents reviewed (Resident 107). Findings include: Physician's orders for Resident 107, dated December 14, 2023, included an order for the resident to receive 10 milligrams (mg) of Oxycodone HCL every six hours as needed for pain. However, the resident's Medication Administration Record (MAR) for January 2024 revealed that the resident was administered 5 mg Oxycodone on January 17 and January 20, 2024, and not the 10 mg that was ordered. Interview with Registered Nurse 6 on March 7, 2024, at 2:43 p.m. confirmed that Resident 107 only received 5 mg of Oxycodone on January 17 and 20, 2024, and not the 10 mg he was ordered. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that fall prevention interventions were in place as ordered and care planned for one of 41 residents reviewed (Resident 19). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated December 5, 2023, revealed that the resident was understood, could understand, had a diagnosis which included a cerebral vascular accident (CVA - commonly known as a stroke), and had two or more falls with no injuries since his admission to the facility. A care plan for the resident, dated December 5, 2023, revealed that the resident was at risk for falls and that the resident was to have bilateral fall mats. Physician's orders for Resident 19, dated November 28, 2023, included an order for the resident to have bilateral fall mats. Nursing notes for Resident 19, dated December 4, 2023, and January 1, 2, 6, 7, and 8, 2024, revealed that staff entered the resident's room and found the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and clinical record reviews, as well as staff interviews, it was determined that the facility failed to complete a safety assessment for one of 41 residents reviewed (Resident 49) who used top side rails for mobility. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 49, dated February 19, 2024, revealed that the resident was understood and could understand, and had a diagnosis of arthritis (inflammation or swelling of one or more joints). Observations of Resident 49 lying in his bed on March 6, 2024, at 10:06 a.m. revealed that the bed had bilateral top side rails. A review of Resident 49's clinical record revealed no documented evidence that a side rail safety assessment had been conducted prior to the use of bilateral top side rails for mobility purposes. An interview with Nursing Home Administrator on March 7, 2024, at 11:04 a.m. confirmed that a side rail safety assessment was not completed for Resident 49 and should have been. 28 Pa. Code 211.12(d)(5) Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record reviews, review of pharmacy labels for medications, and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled for one of 41 residents reviewed (Resident 107). Findings include: Physician's orders for Resident 107, dated December 14, 2023, included an order for the resident to receive 10 milligrams (mg) of Oxycodone HCL (narcotic pain medication) every six hours as needed for pain. Review of the label on Resident 107's pill card of Oxycodone revealed that the card contained 5 mg tablets and the resident was to receive only one tablet every six hours as needed for pain. Interview with Registered Nurse 6 on March 7, 2024, at 2:43 p.m. confirmed that Resident 107's current physician's order for Oxycodone did not match the label on the card of Oxycodone and it should have. 28 Pa. Code 211.9(h) Pharmacy Services.