Pennsylvania Department of Health
MEADOW VIEW NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MEADOW VIEW NURSING CENTER
Inspection Results For:

There are 146 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 NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments: Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on February 5, 2026, it was determined that Meadow View Nursing 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:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations: Based on observations and interviews with staff it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for two of three ice machines observed. Findings include: Observations of the ice machine in the second floor nutrition room on February 4, 2026, at 8:48 a.m. revealed a dark, removable substance around the seal of the ice machine lid. The parts in the ice machine that the ice dispenses from were covered with a faint black removable substance. Observations of the ice machine in the third floor nutrition room on February 4, 2026, at 8:58 a.m. revealed that the parts in the ice machine that the ice dispenses from were covered with a brown removable substance that had water tracks leading into the ice. Interview with the Environmental Services/Maintenance Director on February 4, 2026, at 9:14 a.m. confirmed the above-mentioned observations. He stated that the ice machines are on a cleaning schedule quarterly and that the first floor ice machine was cleaned January 28, 2026, as per the cleaning schedule. He indicated that the second and third floor ice machines were due to be cleaned last week; however, they were not. 28 Pa. Code 211.6 Dietary

Plan of Correction - To be completed: 03/24/2026

The ice machines in the second and third floor nutrition rooms were cleaned at the time the substances were observed. No residents were harmed by the removable substance observed in the ice machines.

All other ice machines were inspected for debris and cleaned if needed.

All ice machines will continue to be cleaned annually per manufacturer's recommendations. In addition, ice machine bins will also be cleaned monthly. Environmental services (EVS) director and team members will be educated by the Administrator or designee on the schedule of cleaning ice machines and as needed.

The administrator or designee will audit adherence to the ice machine cleaning schedules monthly for four months. Ice machines will be visually audited for unanticipated cleaning needs by the dietary department team members or Administrator or designee once per week for four weeks, then monthly for three months. Audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.

483.75(c)(1)-(4)d)(1)(2)(e)(1)-(3)(g)(2)(ii)(iii) REQUIREMENT QAPI/QAA Improvement Activities:

§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.71 and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.71. Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Observations:

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 corrections for a State Survey and Certification (Department of Health) survey ending February 7, 2025, 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 5, 2026, identified repeated deficiencies related to professional nursing services, safe environment free of accident hazards, proper intravenous care, and timely nurse aide performance reviews.

The facility's plan of correction for a deficiency regarding quality of care cited during the survey ending February 7, 2025, revealed that quality of care would be monitored by QAPI. The results of the current survey, cited under F684, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding quality of care.

The facility's plan of correction for deficiencies regarding providing a safe environment free of accident hazards, cited during the survey ending February 7, 2025, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding safety and accident-free environment.

The facility's plan of corrections for deficiencies regarding proper intravenous care, cited during the survey ending February 7, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F694, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding intravenous care.

The facility's plan of correction for a deficiency regarding documentation of nurse aides annual performance evaluations, cited during the survey ending February 7, 2025, revealed that audits of care plans would be completed, and the results would be reported to the QAPI committee for review. The results of the current survey, cited under F730, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding nurse aide performance reviews.

Refer to F684, F689 F694 and F730.

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

Plan of Correction - To be completed: 03/24/2026

No residents were identified as harmed by the unsuccessful implementation of previous plans to ensure compliance with former deficiencies.

The administrator will educate the quality assurance and performance improvement (QAPI) committee members on the current plan to become compliant with concerns of quality of care F684, safety and accident-free environment F689, intravenous care F694, and nurse aide performance reviews F730 including ongoing audit goals to ensure sufficient and sustained compliance.

The administrator or designee will audit plan of correction audits for F684, F689, F694, and F730 for completion prior to each Quality Assurance and Performance Improvement (QAPI) meeting they are to be reviewed at. Upon successful completion of each plan of correction for the specified repeated concerns, sustainability of each improvement will be audited by the quality assurance and performance improvement (QAPI) committee members quarterly for three quarters. Audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Plan of Correction - To be completed: 03/24/2026

Preparation and/ or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

Resident representatives for residents 6, 31, 50, and 92 will be informed of the risks and benefits and treatment alternatives for all psychotropic order and Informed consents will be documented and added to the respective residents' clinical records.

Current residents and new admissions will be audited for psychotropic medication to ensure there is documentation of informed consent on the risks, benefits, and treatment alternatives for the change in their clinical record for all psychotropic medications. Any psychotropic medications without documentation on the risks and benefits and treatment alternatives from the audit will have informed consent documented with the resident representative.

Social services department and registered nurse supervisors (RNs) will be educated by the Director of Nursing (DON) or Administrator or designee on the need to obtain informed consent on the risks and benefits and treatment alternatives of all psychotropic medications prior to administration.

Social services department or designee will audit documentation for resident representatives being informed of risks, benefits, and treatment alternatives with consents obtained for all psychotropic medication order changes weekly for four weeks, then monthly for three months with audits reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.

483.10(e)(2) REQUIREMENT Respect, Dignity/Right to have Prsnl Property:

§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.

Observations: Based on review of policies and clinical records, as well as observations and interviews with residents and staff, it was determined that the facility failed to ensure that call bells were within reach for three of 40 residents reviewed (Residents 50, 95 and 97). Findings include: A review of the facility's call bell policy, dated January 19, 2026, indicated that every resident living at the facility will have a means of communicating with staff from their room when they are in need of assistance. Every resident should have the peace of mind knowing that they can summon assistance regardless of their physical limitations. Each call bell is to be strategically located so that it is within the reach of the resident whether lying on their bed or sitting in a chair in their room. Pressure sensitive call bells are available for those residents who have limited dexterity and cannot push the call bell button. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 50, dated January 7, 2026, revealed that the resident was cognitively intact, required assistance with care needs, had a fall since his prior assessment, and had a diagnosis of Alzheimer's disease. A fall risk care plan for Resident 50, dated March 2, 2022, indicated that the resident was at risk for falls due to his impaired vision and had an intervention to keep his call bell in reach to encourage him to use it for assistance. Observation of Resident 50 on February 2, 2026, at 11:23 a.m. revealed that the resident was lying in his bed and his call bell was hanging across his bedside dresser to the left of the resident and behind the resident not within the resident's reach. Interview with the resident at that time indicated that he was unable to locate his call bell. Interview with Licensed Practical Nurse XX (Amber Fletcher) on February 2, 2026, at 11:32 a.m. confirmed that Resident 50's call bell was not in reach and that he is capable of using his call bell for assistance. Observation of Resident 95 on February 2, 2026, at 11:45 a.m. revealed that the resident was sitting in her wheelchair with her overbed table in front of her and her soft touch call bell placed on her bedside dresser located behind her and not in reach. A nurse aide delivered her lunch tray at 11:57 a.m. and left the room without placing her call bell withing reach. Interview with Nurse Aide XX (Taylor Sleasman) on February 2, 2026, at 12:00 p.m. confirmed that Resident 95's call bell was not in reach and should have been. Observation of Resident 97 on February 2, 2026, at 11:36 a.m. revealed that the resident was lying in bed, and his call bell was lying across his recliner chair to the left of his bed and not within reach. Interview with Licensed Practical Nurse XX (Amber Fletcher) on February 2, 2026, at 11:44 a.m. revealed that Resident 97 currently had a urinary tract infection and was confused. She confirmed that his call bell was not in reach and stated that they check on him, but the nurse aide probably forgot to put it back in reach after a.m. care. Interview with the Nursing Home Administrator on February 2, 2026, at 3:30 p.m. confirmed that Resident 50, Resident 95 and 97's call bells should have been within reach and they were not. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 03/24/2026

Residents 50, 95, and 97 were not harmed when their call bells were not within reach. Call bells for residents 50, 95, and 97 were placed within reach at the time they were discovered to be out of reach.

The Director of Nursing (DON) / designee will complete an audit of current residents to ensure call bell is placed in reach for resident use when in room.

Current and new hired team members will be educated by director of nursing or administrator or designee on keeping resident call bells within reach when residents are in their rooms.

Director of Nursing (DON) or Assistant Director of Nursing (ADON) or designee will complete walking rounds three times per week for four weeks, then once weekly for three months to audit that all call bells for residents are within reach when the resident is in their room. Audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for three of 40 residents reviewed (Residents 3, 9, 92).

Findings include:

The facility's medication administration policy, dated January 19, 2026, indicated that medications were to be administered in accordance with the physician's orders, including any required time frame.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 21, 2025, revealed that the resident was cognitively impaired, had pressure ulcers, and received an antibiotic intravenously.

A physician's note for Resident 3, dated November 18, 2025, revealed that the resident had a wound to the left heal that continued to decline. A physician's order was received to administer 3.375 grams of Piperacillin-Tazobactam intravenously every six hours for a left heel wound infection for 14 days.

Review of the resident's Medication Administration Record (MAR) for November 2025 revealed Piperacillin-Tazobactam was not administered on November 26, 2025, at 6:00 a.m. and 6:00 p.m.

Interview with the Director of Nursing on February 5, 2026, at 1:07 p.m. confirmed that there was no documented evidence that Resident 3's Piperacillin-Tazobactam was administered as ordered on the above date and times.

A quarterly MDS assessment for Resident 9, dated December 9, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, received insulin (medication that lowers blood sugar levels), and had diagnoses that included diabetes.

Physician's orders for Resident 9, dated September 12, 2025, included an order for the resident to receive Lispro Insulin 100 unit/ml according to a sliding scale (the amount of insulin is based on the result of a fingerstick blood sugar test) before meals and at bedtime. (scheduled for 5:00 a.m., 12:30 p.m., 5:30 p.m., 9:30 p.m. on Monday, Wednesday and Friday and 7:30 a.m., 12:30 p.m., 5:30 p.m., 9:30 p.m. on Tuesday, Thursday, Saturday and Sunday). The sliding scale included giving 0 units of insulin for a blood sugar of 70-140 milligrams/deciliter (mg/dl), 2 units for a blood sugar of 141-180 mg/dL, 4 units for a blood sugar of 180-220 mg/dL, 6 units for a blood sugar 221-260 mg/dL, 8 units for a blood sugar of 261-300 mg/dL, 10 units for a blood sugar of 301-340 mg/dl, 12 units for a blood sugar 341 mg/dL or greater, and to notify the physician for further orders.

Resident 9's Medication Administration Record (MAR) for November 2025 revealed that the residents blood sugar results were greater than 341 mg/dL at 12:30 p.m. on November 17 and 26, 2025; at 5:30 p.m. on November 1, 15 and 16, 2025; at 9:30 p.m. November 18, 2025. There was no documented evidence that the physician was notified that the resident's sliding scale blood sugar results were greater than 341 mg/dL on the dates and times mentioned.

Resident 9's MAR for December 2025 revealed that the residents blood sugar results were greater than 341 mg/dL at 12:30 p.m. on December 23, 2025, and 9:30 p.m. on December 22, 2025. There was no documented evidence that the physician was notified that the resident's sliding scale blood sugar results were greater than 341 mg/dL on the dates and times mentioned.

Resident 9's MAR for January 2026 revealed that the residents blood sugar results were greater than 341 mg/dL at 7:30 a.m. on January 6, 2026; at 12:30 p.m. on January 26, 2026, and at 9:30 p.m. on January 10, 2026. There was no documented evidence that the physician was notified that the resident's sliding scale blood sugar results were greater than 341 mg/dL on the dates and times mentioned.

Interview with the Nursing Home Administrator February 5, 2026, at 11:19 a.m. confirmed that the physician should have been notified when Resident 9's sliding scale results were 341 mg/dL or greater.

A quarterly MDS assessment for Resident 92, dated January 15, 2026, revealed that the resident was cognitively impaired, received insulin, and had a diagnosis of diabetes.

Physician's orders for Resident 92, dated October 22, 2024, included an order for the resident to have her blood sugar checked before meals and at bedtime and for staff to administer insulin (medication used to lower blood sugar) per a sliding scale (dose is based on a person's blood sugar).

Physician's orders for Resident 92, dated July 26, 2024, included an order for the resident to have a blood glucose protocol including steps for blood glucose results of 60-80 milligrams per deciliter (mg/dl), 50-59 mg/dl, less than 50 mg/dl and greater than 400 mg/dl as needed/as follows: If blood glucose 60-80 mg/dl give 120 milliliters (ml) of juice and recheck in 15 minutes. Repeat treatment if blood glucose is less than 80 mg/dl; If blood glucose is between 50-59 mg/dl, administer one Glucose Gel if able to swallow or one Glucagon injection if unable to swallow and recheck glucose in 15 minutes. Repeat treatment if glucose is between 50-59 mg/dl; If blood glucose is less than 50 mg/dl, administer two Glucose gels if able to swallow or two Glucagon injections if unable to swallow. Notify the physician if blood glucose is greater than 400 mg/dl or less than 60 mg/dl. Notify physician during normal office hours if blood glucose was less than 50 mg/dl and interventions were effective.

Review of Resident 92's MAR for October 2025 through February 2026 revealed that the resident's blood sugar on October 22, 2025, at 5:30 p.m. was 76 mg/dl; on November 4, 2025, at 7:30 a.m. was 71 mg/dl; on December 12, 2025, at 7:30 a.m. was 73 mg/dl; on December 15, 2025, at 5:30 p.m. was 75 mg/dl ; on January 5, 2026, at 5:30 p.m. was 50 mg/dl ; on January 9, 2026, at 7:30 a.m. was 70 mg/dl ; on January 22, 2026, at 7:30 a.m. was 70 mg/dl; on January 25, 2026, at 7:30 a.m. was 74 mg/dl; on January 29, 2026, at 8:30 p.m. was 72 mg/dl; and on February 1, 2026, at 7:30 a.m. was 74 mg/dl. There was no documented evidence that the blood sugar protocol was followed as ordered.

Interview with the Nursing Home Administrator on February 4, 2026, at 12:23 p.m. confirmed that there was no documented evidence that Resident 92's blood sugar protocol was followed as ordered on the above-mentioned dates and times.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Plan of Correction - To be completed: 03/24/2026

Resident 3 was unharmed and received their entire 14 days of antibiotics by extending their order for the one day the antibiotic was not administered. Residents 9 and 92 were unharmed from the incomplete documentation of the execution of their blood sugar order protocol.

No residents were harmed from incomplete blood sugar protocol or incomplete antibiotic administration documentation. A 30 day review of residents with physician orders for antibiotics and blood sugar protocol orders will be completed to ensure documentation of their order and protocols were followed. Any incomplete documentation will be reviewed with the physician.

Current licensed practical nurses (LPNs) and registered nurse supervisors (RNs), agency nurses and new hired licensed nurses will be educated by the Director of Nursing (DON) or Administrator or designee on following and completely documenting administration of antibiotics as per physician orders and following and completely documenting physician orders for blood sugar protocols including provider notification if needed.

Director of nursing (DON) or Assistant Director of Nursing (ADON) or designee will audit documentation of antibiotic administration and blood sugar protocol followed five days a week for four weeks, then weekly for four weeks then once per month for three months to audit that all physician orders for antibiotics and blood sugar protocol are followed and documented. Audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.

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

§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 clinical records, including an incident report, as well as observations, and staff interviews, it was determined that the facility failed to ensure that fall prevention interventions were in place as care planned for one of 40 residents reviewed (Resident 31), and that a thorough investigation was conducted to determine the safety of the shower chair for one of 40 residents reviewed (Resident 66).

Findings include:

The facility's policy regarding fall management, dated January 19, 2026, indicated that the purpose was to reduce the risk of falls and prevent injury. The facility would mitigate accidents by providing an environment that remains as free of hazards as possible over which the facility has control and each resident receives adequate supervision and assistive devices. The facility identifies each resident at risk for accidents and/or falls and adequately plans care and implements procedures to manage avoidable accidents.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 31, dated January 14, 2026, revealed that the resident was severely cognitively impaired, moderately impaired for vison and speech, sometimes understood and sometimes understands, lived in the memory care unit, had diagnoses that included Alzheimer's disease, dementia, anxiety, history of mental, behavioral and delusional disorders with disturbances that required assistance from two staff to transfer the resident The resident's care plan, revised on May 22, 2025, indicated that she was at risk for falls related to poor safety awareness, confusion and a history of falls, and was to have a sensor pad/alarm/ to her bed and chair. An incident note, dated January 3, 2026, at 7:30 p.m. indicated that the resident had a witnessed fall in the memory unit common area/solarium that resulted in a hip fracture.

A review of the fall incident report, and multiple witness statements dated, January 3, 2026, indicated that Resident 31 was restless and was assisted from her recliner to a chair at a round table in the common area/solarium. The resident pushed herself to a standing position and fell. The resident did not have the sensor pad/alarm on the chair she was sitting in, per her care plan, at the time of her fall.

Interview with the Nursing Home Administrator on February 5, 2026, at 1:10 p.m. indicated that she questioned that the absence of the chair alarm would have prevented the fall. This surveyor confirmed that Resident 31 did not have her care planned fall intervention, the sensor pad/alarm placed on the chair she was sitting in.

The facility's policy for Durable Medical Equipment (DME) dated December 31, 2025 revealed that the facility will ensure that all DME used by residents is clinically appropriate, properly ordered, safely maintained, and in compliance with federal, state, and facility requirements. All DME will be obtained, maintained, and used in a manner that promotes resident safety and quality of care.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 66, dated December 24, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care, assistance of one staff for bathing/showers and had a diagnosis of morbid obesity.

An incident report for Resident 66, dated January 18, 2025, at 4:20 p.m. revealed that the resident was seated in a shower chair in the shower room. While the resident was sitting in the shower chair one of the supportive connections of the PVC (a rigid, durable and corrosion- resistant thermoplastic) pipe cracked weakening the strength of the chair. Resident 66 did not fall through the chair. A nursing assessment was completed at the time of the incident that revealed no injuries. He was transferred to his wheelchair and taken back to his room. The shower chair was removed from service by the director of maintenance.

Interview with the Director of Maintenance and the Nursing Home Administrator February 3, 2026, at 1:35 p.m. revealed that the chair was taken out of service immediately and it was disposed of. The Maintenance Director stated that the shower chairs are inspected monthly and if there are any concerns with the chairs it is immediately corrected and documented as to what the corrective action was. Review of four months of the inspections revealed that the chair was last inspected December 24, 2025 and there were no reported concerns with the shower chair. The inspection documentation listed each shower chair by number and not a specific model number or weight limit.

Observation in the second floor shower room February 4, 2026, at 9:36 a.m. revealed 2 shower chairs that were labeled with the model number and the weight limit. Interview with the Maintenance Director at that time revealed that the chairs observed in the shower room were in service and being used by staff for resident care.

Interview with the Nursing Home Administrator February 4, 2026, at 2:47 p.m. revealed the she did not have documentation of the model number or the weight limit of the shower chair that was used for Resident 66 on January 18, 2026.

Interview with the Nursing Home Administrator February 5, 2026, at 11:23 a.m. confirmed that the investigation that was completed concerning the incident on January 18, 2026 did not determine the safety of the shower chair that was used for Resident 66 and it should have.

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

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

Plan of Correction - To be completed: 03/24/2026

Resident 66 was unharmed and did not fall despite not having documentation that the shower chair was safe for him to use. The shower chair was removed from use when a support pipe cracked. Resident 66 has used shower chairs or other shower assistive durable medical equipment (DME) that are labelled as appropriate and safe for him to use since.

Resident 31 could not have their care-planned sensor pad/alarm in place at the time of the fall due to self-ambulating to the chair prior to fall. A staff member maintained visual supervision of resident 31 until another staff could retrieve sensor pad. Resident 31 stood from the chair and fell prior to staff member could intervene. Resident 31 was successfully treated for their injury.

The Director of Nursing (DON) / designee completed an audit of current residents with care plan for sensor pad alarms were in place.

Certified nursing assistants (CNAs), licensed practical nurses (LPNs), and registered nurse supervisors (RNs), agency staff and new hired staff will be educated by Director of Nursing (DON) or Administrator or designee on ensuring all care-planned sensor pads/alarms are in place and placing sensor pads after assisting residents who self-ambulate. Certified nursing assistants (CNAs), licensed practical nurses (LPNs), and registered nurse supervisors (RNs) and agency staff and hew hired staff will be educated on appropriate durable medical equipment (DME) for resident use and ensuring medical equipment is safe for use.

Director of nursing (DON) or Assistant Director of Nursing (ADON) or designee will complete audits for residents with care-planned sensor pads / alarms to ensure they are in place three times per week for four weeks, then monthly for three months. Assistant Director of Nursing (ADON) or Environmental Safety (EVS) director or designee will audit that durable medical equipment (DME) was safe for use weekly for four weeks, then monthly for three months. Audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that interventions were in place to prevent urinary tract infections for one of 40 residents reviewed (Resident 3) who had an indwelling urinary catheter.

Findings include:

The facility policy for urinary catheters, dated January 19, 2026, revealed that clean technique was to be used when handling the catheter, tubing or drainage bag.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 21, 2025, revealed that the resident was cognitively impaired, dependent on staff for daily care needs, was frequently incontinent of urine, had pressure ulcers, and had diagnoses that included dementia.

Physician's orders for Resident 3, dated December 24, 2025, included an order for the resident to have an indwelling urinary catheter (a flexible tube inserted and held in the bladder to drain urine) for wound healing.

Observations of Resident 3 on February 5, 2026, at 9:34 a.m. revealed that she was in bed and her catheter drainage tubing was in direct contact with the floor.

Interview with Licensed Practical Nurse 1 on February 5, 2026, at 9:38 a.m. confirmed that the catheter tubing was on the floor and should not have been.

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

Plan of Correction - To be completed: 03/24/2026

Resident 3 was unharmed from the isolated incident of her catheter tubing in contact with the floor. At the time of finding the tubing in contact with the floor, it was adjusted so that it was no longer in contact with the floor.

Current residents with indwelling urinary catheters had their catheter tubing visually inspected when resident 3's tubing was found to be in contact with the floor. No other residents were found to have their catheter tubing in contact with the floor.

Certified nursing assistants (CNAs), licensed practical nurses (LPNs), and registered nurse supervisors (RNs), agency staff and new hired staff will be educated by the Director of Nursing (DON) or Administrator or designee on ensuring residents' catheter tubing is not in contact with the floor.

Director of nursing (DON) or Assistant Director of Nursing (ADON) or designee will visually audit all residents with catheters to ensure their catheter tubing is not in contact with the floor three times per week for four weeks, then four times per month for three months. Audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.

483.25(h) REQUIREMENT Parenteral/IV Fluids:

§ 483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that long-term intravenous catheters were flushed per physician's order and facility policy for one of 40 residents reviewed (Resident 120).

Findings include:

The facility's policy regarding the flushing of peripheral (PICC) and midline intravenous catheters (a catheter that is placed in a peripheral vein for long-term administration of fluids and/or medication), dated January 19, 2026, indicated that the peripheral or midline catheter was to be flushed with 10 cubic centimeters (cc's) of normal saline (sterile salt and water solution) every shift and after each use with 5-10 cc's of normal saline and 5 cc's of Heparin (blood thinner), if physician's orders indicated.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 120, dated December 11, 2025, indicated that the resident was cognitively intact, was understood and able to understand others, required assistance with care needs, received an intravenous medication, and had a diagnosis of cancer. A nursing note, dated December 5, 2025, revealed the resident was admitted to the facility and had a PICC line to his left upper arm.

Physician's orders for Resident 120, dated December 5, 2025, included an order for the resident to have each port of his PICC line flushed with 10 cc's of normal saline every shift.

Review of the Medication Administration Record (MAR) for Resident 120 for December 2025 and January 2026 revealed that there was no documented evidence that both ports of the resident's PICC line were flushed every shift on December 7, 9, 14, 16, 18, 21, 24, and 30, 2025, and January 6, 12, 14, 17, 18, 19, 21-25, and 29, 2026.

Interview with the Nursing Home Administrator on February 5, 2026, at 12:44 p.m. confirmed that there was no documented evidence that Resident 120's PICC line was flushed every shift as ordered by the physician and per facility policy.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Plan of Correction - To be completed: 03/24/2026

Resident 120 discharged from Meadow View Nursing Center and therefore no longer has an active order for peripheral intravenous catheter (PICC) (a catheter that is placed in a peripheral vein for long-term administration of fluids and/or medication) flushes.

A 30 day review of PICC line flushes will be completed, no other residents with peripheral intravenous catheters (PICC) were identified as missing documentation of physician ordered flushes during the time of the survey.

Licensed practical nurses (LPNs) and registered nurse supervisors (RNs) will be educated by Director of Nursing (DON) or Administrator or designee on following and documenting physician orders for peripheral intravenous catheters (PICC) flushes on the medication administration record (MAR).

The director of nursing (DON) or assistant director of nursing (ADON) or designee will audit documentation of physician ordered peripheral intravenous catheters (PICC) flushes five days a week for four weeks, then once a week for four weeks then once per month for three months for complete documentation. Audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

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 minute (lpm) of oxygen via nasal cannula (tube that delivers oxygen through the nose). There was no documented evidence that a physician's order was obtained for Resident 2 to use oxygen during this time.

Medication Administration Records (MAR's) and Treatment Administration Records (TAR's) for November 2025 revealed that there was no documented evidence that Resident 2 used oxygen.

An admission MDS assessment for Resident 24, dated January 18, 2026, revealed that the resident was cognitively impaired, dependent on staff for daily care tasks, and had diagnoses that included heart disease. A care plan, dated January 4, 2026, indicated that Resident 24's oxygen was to be administered as ordered.

A nursing note for Resident 24, dated January 12, 2026, at 11:38 p.m. revealed the resident returned from the hospital and was using 2 lpm of oxygen. Nursing notes dated January 13 at 11:23 a.m., January 14 at 6:36 p.m., January 15 at 8:47 a.m., January 17 at 12:26 p.m., and January 18, 2026 at 11:43 a.m., revealed the resident was using 2 lpm of oxygen via nasal cannula. There was no documented evidence that a physician's order was obtained for Resident 24 to use oxygen during this time.

Medication Administration Records (MAR's) and Treatment Administration Records (TAR's) for January 2026 revealed that there was no documented evidence that Resident 24 used oxygen during this time.

Interview with the Nursing Home Administrator on February 4, 2026, at 1:40 p.m. confirmed that there was no physician's order for Resident 2 and 24's use of oxygen.

28 Pa. Code 211.12(d)(3)(5) Nursing services.

Plan of Correction - To be completed: 03/24/2026

Resident 2 and resident 24 were unharmed from not having a documented order to support their oxygen needs. Resident 2 and resident 24 had their oxygen use and orders reconciled to match based on clinical determination of need.

Current residents using oxygen had their orders reviewed to ensure they had an order for oxygen.

Licensed practical nurses (LPNs) and registered nurse supervisors (RNs), new hires and agency licensed staff will be educated by Director of Nursing (DON) or Administrator or designee on ensuring all residents using oxygen have a provider order before administering oxygen.

The director of nursing (DON) or Assistant Director of Nursing (ADON) or designee will audit oxygen orders for all residents using oxygen once per week for four weeks, then once per month for three months to ensure each resident using oxygen has a corresponding physician order. Audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.

483.35(e)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:

§483.35(e)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Observations:

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 2revealed 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.

Plan of Correction - To be completed: 03/24/2026

No residents were harmed by nurse aide 2 not having a performance evaluation within the previous 12 months. Nurse aide 2 will have a performance evaluation completed.

Current nurse aide files will be reviewed to ensure performance evaluations are complete; any incompletions will be completed by March 24,2026.

The director of nursing (DON) and Assistant Director of Nursing (ADON) will be educated by Administrator or designee on completing performance evaluations annually. Evaluations will be completed each year during the month of employee's hire date unless any evaluations are found to be overdue. Overdue evaluations will be completed upon discovery.

The administrator or designee will audit all performance reviews due for completion every week for four weeks, then monthly for three months. Audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.

§ 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: 03/24/2026

The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Scheduler will be educated on the state requirement for nursing hours including the Certified Nurse Assistants (CNA) to resident ratios by the Quality Clinical Consultant/designee.

Staffing meetings will be held three days a week to review and audit the Certified Nurse Assistant (CNA) ratio from the previous two days and the projected Certified Nurse Assistant ratio for the current day, as well as the upcoming week to ensure appropriate staffing levels by the Nursing Home Administrator/ designee.

If projected staffing ratios do not meet minimum, the facility will reach out to current staff and local staffing agencies to meet the minimum requirement. Facility will continue to recruit staff through all platforms.

Audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.

§ 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 review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurse for 40 Residents on the night shift for 3 of 21 days (24-hour periods) reviewed.

Findings Include:

Review of facility census data indicated that on January 17, 2026, the facility census was 134, which required 3.35 Licensed Practical Nurses (LPN) during the night shift. Review of the nursing time schedules revealed 3.30 LPNs worked on the night shift on January 17, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 21, 2026, the facility census was 133, which required 3.33 Licensed Practical Nurses (LPN) during the night shift. Review of the nursing time schedules revealed 3.00 LPNs worked on the night shift on January 21, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 2, 2026, the facility census was 125, which required 3.13 Licensed Practical Nurses (LPN) during the night shift. Review of the nursing time schedules revealed 2.06 LPNs worked on the night shift on February 2, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Interview with the Nursing Home Administrator on February 5, 2026, at 5:00 p.m. confirmed that the facility did not meet the required Licensed Practical Nurse-to-resident staffing ratios for the days listed above.

Plan of Correction - To be completed: 03/24/2026

The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Scheduler will be educated on the state requirement for nursing hours including the Licensed practical nurses to resident ratios by the Quality Clinical Consultant/designee.

Staffing meetings will be held three days a week to review/audit the Licensed Practical nurse ratio from the previous two days and the projected Licensed Practical nurse ration for the current day, as well as the upcoming week to ensure appropriate staffing levels by the Nursing Home Administrator/ designee.

If projected staffing ratios do not meet minimum, the facility will reach out to current staff and local staffing agencies to meet the minimum requirement. Facility will continue to recruit staff through all platforms.

Audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.

§ 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 review of nursing schedules and staff interviews, it was determined that the facility failed to provide 3.20 hours of direct resident care for each resident for one of 21 days (24-hour periods) reviewed.

Findings include:

Nursing time schedules provided by the facility for the days of January 11, through January 17, January 21, through January 27, and January 29, through February 4, 2026, revealed that the facility provided only 3.17 hours of direct care for each resident on January 17, 2026.

Interview with the Nursing Home Administrator on December 5, 2026, at 5:00 p.m. confirmed that the facility did not meet the required daily PPD on the day listed above.

Plan of Correction - To be completed: 03/24/2026

The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Scheduler will be educated on the state requirement for nursing hours per day by the Quality Clinical Consultant/designee.

Staffing meetings will be held three days a week to ensure/audit nursing hours meet state requirements, as well as the upcoming week to ensure appropriate staffing levels by the Nursing Home Administrator/ designee.

If projected staffing ratios do not meet minimum, the facility will reach out to current staff and local staffing agencies to meet the minimum requirement. Facility will continue to recruit staff through all platforms.

Audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.

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