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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MEADOW VIEW REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are 79 surveys for this facility. Please select a date to view the survey results.

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MEADOW VIEW REHABILITATION & HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit survey completed on June 9, 2025, it was determined that Meadow View Rehabilitation and Healthcare Center corrected the federal deficiencies cited during the survey of May 13, 2025, under 42 CFR Part 483 Subpart B Requirements for Long Term Care but was out of compliance under 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.

Plan of Correction - To be completed: 06/27/2025

1. The facility cannot retroactively correct CNA staffing ratio.
2. NHA/designee will conduct an initial audit of the past two weeks scheduled to determine if CNA staffing ratio is in compliance.
3. NHA/designee will re-educate the scheduler on the proper CNA staffing ratio. The facility will continue to recruit and attempt to hire new staff. The facility will hold
labor meetings Monday-Friday to verify CNA staffing ratio is made.
4. NHA/designee will conduct random audits of facility CNAstaffing ratios x for 4 weeks, then monthly for 2 x monthsthereafter to verify proper CNA staffing ratios. Results of audits will be reviewed by the QAPI Committee and changes will be made as necessary.

§ 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 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 4 shifts out of 21 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 and 1:40 on the night shift based on the facility's census.

June 2, 2025 - 1.00 LPN on the night shift, versus the required 1.18 for a census of 47
June 3, 2025 - 0.97 LPNs on the night shift, versus the required 1.28 for a census of 51.
June 7, 2025 - 1.00 LPN on the night shift, versus the required 1.38 for a census of 55.
June 8, 2025 - 1.88 LPN on the day shift, versus the required 2.20 for a census of 55.

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

An interview with the Nursing Home Administrator on June 9, 2025, at 4:00 PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.

Plan of Correction - To be completed: 06/27/2025

1. The facility cannot retroactively correct LPN staffing ratio.
2. NHA/designee will conduct an initial audit of the past two weeks scheduled to determine if LPN staffing ratio is in compliance.
3. NHA/designee will re-educate the scheduler on the proper LPN staffing ratio. The facility will continue to recruit and attempt to hire new staff. The facility will hold labor meetingsMonday-Friday to verify LPN staffing ratio is made.
4. NHA/designee will conduct random audits of facility LPNstaffing ratios weekly x 4 weeks, then month x 2 monthsthereafter to verify proper LPN staffing ratios. Results of audits will be reviewed by the QAPI, and changes will be made as necessary

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(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 7 shifts out of 21 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.

June 2, 2025 - 0 RNs on the night shift, versus the required 1 for a census of 47.
June 3, 2025 - 0 RNs on the night shift, versus the required 1 for a census of 51.
June 4, 2025 - 0 RNs on the night shift, versus the required 1 for a census of 53.
June 5, 2025 - 0 RNs on the night shift, versus the required 1 for a census of 55.
June 6, 2025 - 0 RNs on the night shift, versus the required 1 for a census of 55.
June 7, 2025 - 0 RNs on the night shift, versus the required 1 for a census of 55.
June 8, 2025 - 0 RNs on the night shift, versus the required 1 for a census of 55.

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

An interview with the Nursing Home Administrator on June 9, 2025, at 4:00 PM, confirmed the facility had not met the required RN to resident ratios on the above dates.

Plan of Correction - To be completed: 06/27/2025

1. The facility cannot retroactively correct RN staffing ratio.
2. NHA/designee will conduct an initial audit of the past two weeks scheduled to determine if RN staffing ratio is in compliance.
3. NHA/designee will re-educate the scheduler on the proper RN staffing ratio. The facility will continue to recruit and attempt to hire new staff. The facility will hold labor meetings Monday-Friday to verify RN staffing ratio is made.
4. NHA/designee will conduct random audits of facility RN staffing ratios weekly x 4 weeks, then month x 2 months thereafter to verify proper RN staffing ratios. Results of audits will be reviewed by the QAPI, and changes will be made as necessary

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, 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 3.2 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 3.2 hours of general nursing care to each resident:
June 2, 2025 - 3.14 direct care nursing hours per resident.
June 3, 2025 - 3.01 direct care nursing hours per resident.
June 4, 2025 - 3.01 direct care nursing hours per resident.
June 5, 2025 - 2.78 direct care nursing hours per resident.
June 6, 2025 - 2.89 direct care nursing hours per resident.
June 7, 2025 - 2.73 direct care nursing hours per resident.
June 8, 2025 - 2.98 direct care nursing hours per resident.

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

An interview with the Nursing Home Administrator on June 9, 2025, at 4:00 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 06/27/2025

1.The facility cannot retroactively correct the minimum number of 3.2 hours of direct care to each resident for cited dates.
2. NHA/Designee will conduct initial audit of past two weeks to determine if minimum number of 3.2 hours complies
3. NHA will re-educate the Scheduler on the updated staffing regulations in relation to the minimum staffing hours of 3.2 hours of direct care for each resident. The facility will hold labor meetings Monday-Friday to verify minimum number of 3.2 hours of direct care is made.
4. NHA/designee will conduct random audits of facility minimum number of staffing hours of 3.2 to each resident weekly x 4 weeks then monthly x 2 months. The results of the audits will be reviewed at QAPI committee for further review and changes will be made as necessary.

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