Pennsylvania Department of Health
ROSE MEADOWS HEALTH & REHAB CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ROSE MEADOWS HEALTH & REHAB CENTER
Inspection Results For:

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ROSE MEADOWS HEALTH & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to two complaints, completed on February 19, 2026, it was determined that Rose Meadows Health and Rehab Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

�483.25(d) Accidents.
The facility must ensure that -
�483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

�483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance.

Findings include:

Review of the facility policy "Abuse Policy-Prevention and Identification," dated 4/17/25, indicated it is the facility's policy to "deploy staff on each shift in sufficient numbers and assure staff assigned have knowledge of the individual residents' care needs".

Review of the clinical record indicated Resident R1 was admitted to the facility on 1/5/26.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/11/26 included diagnoses of cellulitis (bacterial infection affecting the skin's deep layers) and muscle weakness. Review of Section GG: Functional Abilities indicated that Resident R1 required "dependent assistance (two or more helpers)" for chair/bed-to-chair transfers.
Review of an on-call physician note dated 2/5/26 at 4:12 p.m. indicated, "nurse calls to report resident was being assisted back to bed earlier and hit his left leg on the edge of the bed and caused a laceration. Per nurse measurements are 6cmx 0.5x0.25. Some bleeding earlier but not currently bleeding."

Review of a progress note dated 2/5/26 at 6:03 p.m. indicated, "CNA alerted this nurse that resident was bleeding from left lateral leg. Upon inspection this nurse observed a 6cmx0.5cmx0.0cm laceration to the left lateral lower leg. This resident stated, 'My leg got dragged on the side of the bed when being transferred from my wheelchair to bed'."

Review of facility submitted information on 2/5/26, indicated on 2/5/26 at 4:00 p.m., " [Resident R1] reported that when was being transferred from his wheelchair to his bed by CNA [nurse aid], when his left leg hit the bed and he sustained a cut. Resident was assessed by the RN (registered nurse) and telehealth was completed. First aide provided to the resident per MD (medical doctor) order. Area was cleansed and Steri strips applied and area covered with dry dressing."

Review of an employee statement via phone by NA Employee E1, dated 2/5/26 indicated, "transferred the resident from the wheelchair to the bed without another employee".

Review of Resident R1's plan of care for "ADLs (activities of daily living) Functional Status / Rehabilitation Potential," not initiated until 2/6/26, indicated that the resident will have staff assist of two with all transfers for safety. The plan of care did not indicate assist of two prior to 2/6/26.

Review of the facility's plan of correction included:

-Wound will be monitored for signs/symptoms of infection.

-Nursing care plan updated to include any new orders.

-Interventions are put into place to prevent injuries or reduce the risk of injuries for individual resident needs.

-All residents are assessed on admission, quarterly and upon incident for appropriate care plan adjustments.

-All incidents and accidents are tracked and trended by the quality assurance committee and reviewed for recommendations to prevent injuries.

Review of facility provided education information and on-going quality assurance measures revealed facility staff received education on accident prevention, falls, and reviewing ADL information in the computerized charting system, as well as ongoing monitors to prevent future accidents and improve systems. This education was completed on 2/17/26 and was in compliance as of that date.

During an interview on 2/19/26 at approximately 11:15 a.m., the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(e)(1) Management.

28 Pa. Code 201.29(a) Resident rights.

28 Pa. Code 211.10(c)(d) Resident care policies.

28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 03/03/2026

Past noncompliance: no plan of correction required.

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