Pennsylvania Department of Health
MEADOWS NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MEADOWS NURSING AND REHABILITATION CENTER
Inspection Results For:

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MEADOWS NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Complaint Survey completed on May 30, 2025, it was determined that the Meadows Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on a review of clinical records, the facility's abuse prohibition policy, select investigative documentation, and interviews with the resident and facility staff, it was determined the facility failed to protect one of five sampled residents (Resident 18) from neglect by not implementing the physician-ordered use of a mechanical lift for all transfers, resulting in actual harm in the form of a comminuted right tibia and fibula fracture requiring surgical intervention.

Findings include:

A review of the facility policy titled "Investigation of Allegations of Abuse, Neglect or Misappropriation of Resident Property" provided on May 30, 2025, revealed the facility will provide each resident with the highest practicable physical, mental and psychological services to meet their individual needs and promote or maintain the resident at their highest level of wellbeing. This includes the protection of Resident's Rights. Allegations of abuse will be thoroughly investigated by the facility. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

A review of Resident 18's clinical record revealed admission to the facility on November 6, 2023 with diagnosis that included osteoarthritis (a degenerative joint disease that occurs when tissues that cushion the ends of bones within the joints break down), rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing joint pain, stiffness, inflammation, and eventually joint damage), and a periprosthetic fracture around the internal prosthetic right knee joint (a bone fracture that occurs near the knee replacement implant).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 7, 2025, revealed that Resident 18 was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment). Continued review revealed the resident required total staff assistance to shower and total staff assistance for transfers.

Review of the resident's plan of care dated November 6, 2023, indicated that Resident 18 had an ADL self-care performance deficit related to impaired balance, rheumatoid arthritis, osteoarthritis, and periprosthetic fracture of the right knee. Interventions included non-weight bearing to the right lower extremity (leg), and use of a Hoyer lift with a green sling (a lift that uses hydraulic power to transfer a person while cradled in a sling).

A physician's order dated February 18, 2024, revealed an order for Resident 18 to maintain non-weight bearing through the right lower extremity and to use a Hoyer lift with a green sling for transfers.

Review of Resident 18's electronic Kardex (quick reference for staff that includes summary of resident information to provide care) also noted the resident was non-weight bearing to the right lower extremity and the resident transfers using a Hoyer lift with a green sling.

Nursing documentation dated May 13, 2025, at 12:08 AM revealed Resident 18 was complaining of pain in her right shin and foot on the 11PM-7AM shift. The resident told the night shift nurse she had hurt it while getting a shower on the 3PM- 11PM shift the prior evening, May 12, 2025. The night shift supervisor contacted the physician and an X-ray was obtained, which showed a moderately comminuted fracture of the mid shaft of the right tibia and mildly displaced slightly angulated and comminuted fracture of the mid shaft of the right fibula. The resident was transferred to the emergency department and underwent an open reduction and internal fixation (ORIF) with intramedullary nailing (intramedullary nail-a metal rod that is inserted into the bone to stabilize fractures) and anteromedial plating (surgical implant used in the fixation of fractures) on May 14, 2025.

A review of facility-provided investigative documentation dated May 13, 2025, at 11:40 AM revealed the nurse aides involved did not follow the physician-ordered plan of care requiring the use of a full body mechanical lift for transfers. The documentation indicated the facility initiated an internal investigation into the incident, and the staff members were suspended from duty pending the outcome of that investigation.

Review of the witness statement provided by Employee 1 (nurse aide) via telephone interview, by the facility, dated May 13, 2025, at 10:10 AM revealed the following: "We transferred (Resident 18) from her wheelchair into the shower chair". When questioned as to whether the nurse aide knew Resident 18 was a mechanical lift, Employee 1 replied "Yes", she was aware, and the lift was in the shower room at the time. When asked why the mechanical lift was not utilized, Employee 1 responded "I don't know." Employee 1 stated she and Employee 3 (nurse aide) lifted the resident while Employee 2 (nurse aide) pulled the resident's pants down to put her in the shower chair.

Review of the witness statement provided by Employee 2 via a telephone interview by the facility, dated May 13, 2025, at 10:25 AM revealed the following: Employee 1, Employee 2 and Employee 3 transferred Resident 18 into the shower chair. The resident was complaining of her leg hurting before the shower and after the shower, so I told Employee 4 (licensed practical nurse). Employee 4 gave her a pain medication. Resident 18 complains of pain on and off, all the time. When we transferred her, we did not use a Hoyer, three of us transferred her. The resident was thankful for the shower. When questioned as to whether the nurse aide knew Resident 18 was a mechanical lift, the aide replied that it was her mistake, I am sorry. Resident 18 was on the edge of her chair; there was no way to get the sling under her. When questioned why the nurse aides did not boost Resident 18 back in her wheelchair if she was on the edge. Employee replied, "we didn't have time."

Review of the witness statement provided by Employee 3 via a telephone interview by the facility, dated May 13, 2025, at 4:45 PM revealed the following: " I was doing a shower (for another resident), and they asked me to help stand her up (Resident 18). I know she is a Hoyer lift. The asked me to stand her up. They brought her in the shower room, and we put her in the shower chair. We lifted her." Employee 2 pulled out the wheelchair and pushed the shower chair under the resident. When we lifted her up, she was okay. When her pants were coming down, she yelled out. When we sat her down, she started complaining about the right side of her leg. They asked me to lift her, I knew she required a Hoyer lift. Resident said "Ow" after the transfer. The leg she complained of pain was her right leg. Employee 1 was on her right side. Resident 18 was sitting normal in her wheelchair; she did not turn or twist. I then proceeded to give the other resident a shower after Resident 18 was in the shower chair. When questioned about why the mechanical lift was not in use, Employee 3 replied, " I know better, I use the lifts. It is in her chart to use it. They asked for my help, and they just wanted to get her in the shower chair. I did not want the girls to be mad at me. I just didn't want to throw anyone under the bus. They told me to say we used the Hoyer." When questioned about the location of the lift at the time of the transfer, Employee 3 reported that Employee 1 got the lift after Resident 18 was in the shower chair. I'm sorry, Resident 18 does not like to use the machine, they brought her to the shower and needed my help quick.

Review of the facility's investigative documentation provided by the facility dated May 15, 2025, at 2:00 PM revealed the incident occurred on May 12, 2025, at 4:00 PM. Findings of the facility investigation are as follows: After interviewing the resident and the nurse aides it was concluded that Employee 1 and Employee 2 brought Resident 18 to the shower room in her wheelchair. Employee 3 was already in the shower room providing a shower to another resident when Employee 1 and Employee 2 asked Employee 3 for help to transfer Resident 18. Employee 3 and Employee 1 stood Resident 18 while Employee 2 pulled down her pants. Employee 1 and Employee 3 proceeded to transfer the resident onto the shower chair. During the transfer Resident 18 stated she felt her leg give out and then felt severe pain and she yelled out. Employee 3 confirmed the resident yelled out in pain with the transfer and that she was complaining of right leg pain. After the resident was transferred to the shower chair, Employee 3 stated that Employee 1 went and got the full body mechanical lift and sling and brought it into the shower room and told Employee 3 that if anyone asks, "they used the lift".

Continued review confirmed that Resident 18 had a physician order to be transferred with use of a full body mechanical lift and non-weight bearing on the right lower extremity. All three nurse aides admitted to not following the physician order and not using the mechanical lift to transfer Resident 18 to the shower chair. Resident 18 has the following diagnosis which increase her risk of injury: osteoarthritis, osteoporosis, rheumatoid arthritis, periprosthetic fracture around the internal prosthetic right knee joint and right knee pain.

Further review of the facility's documented conclusion of the investigation revealed the three nurse aides had not followed the physician order for the use of the full body mechanical lift and the non-weight bearing status to Resident 18's right lower extremity, which resulted in fractures to her right tibia and fibula with hospital admittance for surgical repair. The investigation substantiated caregiver neglect causing serious physical injury.

During an interview with Resident 18 on May 30, 2025, at 10:45 AM, the resident reported that she requires the use of the lift to get in and out of her wheelchair. She stated, "That's where they were wrong, they never used the lift." She continued " I was falling, and they said, "we have you" and I said, "no you don't". I told them I was falling, and they said you're all right, but I wasn't all right."

A voicemail message was left for Employee 1, 2, and 3 on May 30, 2025, between 11:00 -11:10 AM in an attempt to conduct a telephone interview, however, the surveyor's messages were not returned.

The facility's investigation substantiated neglect resulting in serious physical injury. All three aides involved were suspended during the investigation and subsequently terminated, as confirmed by the Nursing Home Administrator (NHA) during an interview on May 30, 2025. The NHA acknowledged that the nurse aides knowingly failed to implement required safety protocols, resulting in actual harm, right tibia and fibula fracture to Resident 18, requiring hospitalization and surgical repair.

28 Pa. Code 201.14 (a) Responsibility of licensee

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

28 Pa. Code 201.29 (a) Resident Rights

28 Pa. Code 211.12 (d)(5) Nursing Services

Plan of Correction - To be completed: 06/12/2025

1. Resident #18 is being transferred according to physician order with a full body mechanical lift with an assist of two caregivers
2. Current residents with an order for a full body mechanical lift with an assist of two caregivers are being transferred as per physician order.
3. Nurse Aides and Nursing personnel have received re-education on the importance of following Physician orders for transfer status.
Directed in service training provided on federal regulations F600 §42 CFR §483. 12 Freedom from Abuse, Neglect, and Exploitation to licensed and non-licensed nursing staff.
4. DON/Designee will randomly conduct audits of transfer status specifically for resident #18 and random audits on residents with orders for full body mechanical lift.
LNHA/Designee to conduct random audits on Abuse Prevention Protocol.
5. Audits will be presented to Quality Assurance Committee for comments and recommendations.
6. Corrective Action Date: June 12, 2025

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