Pennsylvania Department of Health
 MEADOW VIEW REHABILITATION & HEALTHCARE CENTER
Patient Care Inspection Results

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MEADOW VIEW REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are  73 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
MEADOW VIEW REHABILITATION & HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on June 28, 2024, at Meadow View Rehabilitation and Healthcare Center it was determined that there was no deficient practice, related to the reported complaint allegations, identified under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities but the facility was not in compliance with the following requirements of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 16 shifts out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:12 on the day and evening shift and 1:20 on the night shift based on the facility's census.

May 24, 2024 - 4.20 nurse aides on the evening shift, versus the required 4.42 for a census of 53.
May 26, 2024 - 3.26 nurse aides on the evening shift, versus the required 4.42 for a census of 53.
May 27, 2024 - 3.11 nurse aides on the evening shift, versus the required 4.42 for a census of 53.
May 29, 2024 - 2.77 nurse aides on the evening shift, versus the required 4.50 for a census of 54.
June 7, 2024 - 3.11 nurse aides on the day shift, versus the required 4.50 for a census of 54.
June 7, 2024 - 3.41 nurse aides on the evening shift, versus the required 4.50 for a census of 54.
June 8, 2024 - 3.33 nurse aides on the evening shift, versus the required 4.50 for a census of 54.
June 9, 2024 - 3.49 nurse aides on the evening shift, versus the required 4.50 for a census of 54.
June 10, 2024 - 4.57 nurse aides on the evening shift, versus the required 4.58 for a census of 55.
June 12, 2024 - 4.33 nurse aides on the evening shift, versus the required 4.58 for a census of 55.
June 18, 2024 - 3.99 nurse aides on the day shift, versus the required 4.42 for a census of 53.
June 18, 2024 - 4.21 nurse aides on the evening shift, versus the required 4.42 for a census of 53.
June 20, 2024 - 3.36 nurse aides on the evening shift, versus the required 4.50 for a census of 54.
June 21, 2024 - 4.38 nurse aides on the day shift, versus the required 4.42 for a census of 53.
June 22, 2024 - 3.39 nurse aides on the day shift, versus the required 4.42 for a census of 53.
June 22, 2024 - 3.88 nurse aides on the evening shift, versus the required 4.42 for a census of 53.

On the above dates no additional excess higher-level staff were available to compensate for this deficiency.

An interview with the Nursing Home Administrator on June 28, 2024, at approximately 1:45 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates and shifts.



 Plan of Correction - To be completed: 07/23/2024

1. Facility cannot retroactively correct the alleged deficiency.
2. DON/designee will complete an audit of the last two weeks of CNA staffing ratios to verify compliance.
3. DON/designee to educate nurse administration on minimum nurse aide ratio. labor meetings will be completed throughout the week with DON, NHA, and scheduler to verify compliance of nurse aide ratios.
4. DON/designee to audit CNA staffing ratios 5 times weekly x4 and monthly x 2 to verify compliance. Results will be brought to monthly QAPI meeting.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(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 a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 21 shifts out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shift, 1:30 on the evening shift, and 1:40 on the night shift based on the facility's census.

May 24, 2024 - 1.94 LPNs on the day shift, versus the required 2.12 for a census of 53.
May 25, 2024 - 1.44 LPNs on the day shift, versus the required 2.12 for a census of 53.
May 25, 2024 - 0.94 LPNs on the night shift, versus the required 1.33 for a census of 53.
May 26, 2024 - 1.59 LPNs on the day shift, versus the required 2.12 for a census of 53.
May 26, 2024 - 1.02 LPNs on the night shift, versus the required 1.33 for a census of 53.
May 27, 2024 - 2 LPNs on the day shift, versus the required 2.12 for a census of 53.
May 28, 2024 - 1 LPN on the night shift, versus the required 1.33 for a census of 53.
May 30, 2024 - 2 LPNs on the day shift, versus the required 2.16 for a census of 54.
May 30, 2024 - 1.05 LPNs on the night shift, versus the required 1.35 for a census of 54.
June 7, 2024 - 2.03 LPNs on the day shift, versus the required 2.16 for a census of 54.
June 7, 2024 - 1.67 LPNs on the evening shift, versus the required 1.80 for a census of 54.
June 8, 2024 - 2 LPNs on the day shift, versus the required 2.16 for a census of 54.
June 9, 2024 - 2.04 LPNs on the day shift, versus the required 2.16 for a census of 54.
June 10, 2024 - 1.06 LPNs on the evening shift, versus the required 1.83 for a census of 55.
June 18, 2024 - 1.94 LPNs on the day shift, versus the required 2.12 for a census of 53.
June 19, 2024 - 2 LPNs on the day shift, versus the required 2.16 for a census of 54.
June 20, 2024 - 2.09 LPNs on the day shift, versus the required 2.16 for a census of 54.
June 21, 2024 - 1.81 LPNs on the day shift, versus the required 2.12 for a census of 53.
June 22, 2024 - 2 LPNs on the day shift, versus the required 2.12 for a census of 53.
June 23, 2024 - 1.63 LPNs on the day shift, versus the required 2.12 for a census of 53.
June 23, 2024 - 0.91 LPNs on the evening shift, versus the required 1.77 for a census of 53.

On the above dates mentioned no additional excess higher-level staff were available to compensate for this deficiency.

An interview with the Nursing Home Administrator on June 28, 2024, approximately 1:45 PM, confirmed the facility had not met the required LPN to resident ratios on the above shifts/dates.



 Plan of Correction - To be completed: 07/23/2024

1. Facility cannot retroactively correct the alleged deficiency.
2. DON/designee will complete an audit of the last two weeks of LPN staffing ratios to verify compliance.
3. DON/designee to educate nurse administration on minimum LPN ratio. labor meeting will be completed throughout the week with DON, NHA, and scheduler to verify compliance of LPN ratios.
4. DON/designee to audit LPN staffing ratios 5 times weekly x4 and monthly x 2 to verify compliance. Results will be brought to monthly QAPI meeting.

§ 211.12(f.1)(5) LICENSURE Nursing services. :State only Deficiency.
(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.
Observations:

Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum Registered nurse staff to resident ratio was provided on each shift for 18 shifts out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum Registered nurse (RN) staff of 1:250 on the night shift based on the facility's census.

May 24, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 53.
May 25, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 53.
May 26, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 53.
May 27, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 53.
May 28, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 53.
May 29, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 54.
May 30, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 54.
June 6, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 54.
June 7, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 54.
June 8, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 54.
June 9, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 54.
June 18, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 53.
June 19, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 54.
June 20, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 54.
June 21, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 53.
June 22, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 53.
June 23, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 53.
June 24, 2024 - 0 RNs on the night shift, versus the required 1 for a census of 53.


An interview with the Nursing Home Administrator on June 28, 2024, at approximately 1:45 PM, confirmed the facility had not met the required RN to resident ratios on the above dates.




 Plan of Correction - To be completed: 07/23/2024

1. Facility cannot retroactively correct the alleged deficiency.
2. DON/designee will complete an audit of the last two weeks of RN staffing ratios to verify compliance.
3. DON/designee to educate nurse administration on minimum RN ratio. labor meetings will be completed throughout the week with DON, NHA, and scheduler to verify compliance of RN ratios.
4. DON/designee to audit RN staffing ratios 5 x weekly x4 and monthly x 2 to verify compliance. Results will be brought to monthly QAPI meeting.

§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

May 26, 2024 -2.63 direct care nursing hours per resident.
May 27, 2024 -2.75 direct care nursing hours per resident.
May 29, 2024 -2.74 direct care nursing hours per resident.
June 7, 2024 -2.73 direct care nursing hours per resident.
June 8, 2024 -2.76 direct care nursing hours per resident.
June 22, 2024 -2.73 direct care nursing hours per resident.

The facility's general nursing hours were below the daily minimum required on the dates noted above.

An interview with the Nursing Home Administrator on June 28, 2024, at approximately 1:45 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.



 Plan of Correction - To be completed: 07/23/2024

1. Facility cannot retroactively correct the alleged deficiency.
2. DON/designee will audit of the last two weeks of staffing ppds to verify compliance.
3. DON/designee to educate nursing administration on ppd compliance and census management. labor meetings will be completed throughout the week with DON, NHA, and scheduler to verify compliance of ppds.
4. DON/designee to audit ppd's 5 times weekly x 4 and monthly x 2 to verify compliance. Results will be brought to monthly QAPI meeting.


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