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

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MEADOWS NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 98 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.


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

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and Abbreviated Complaint Survey completed on May 29, 2026, it was determined that 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 Licensure Regulations.

Plan of Correction:

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

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.

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Plan of Correction - To be completed: 07/22/2026

1. Controlled medication shift count records are accurate and complete.
2. Controlled medication shift records on each floor have been audited to ensure compliance with the requirements.
3. Professional nurses have been reeducated on the facility policy, "CONTROLLED MEDICATION receipt, count and secure storage"
4. DON/Designee to audit Controlled medication shift count records on both floors three times per week for one month, then two times per week for one month, and then at least monthly for two quarters.
5. Results of the audits shall be brought to Quality Assurance Committee for review and recommendations.
6.Corrective Action Date: July 22, 2026

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

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.

§483.12 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;

Plan of Correction - To be completed: 07/22/2026

1. Resident 74 is free from abuse and has no negative affects.
2. Resident 12 resides in a semi-private without a roommate and will not be assigned a roommate. Resident 12 is on safety checks, which document the location of resident 12 every 15 minutes. Facility investigation was completed and did not substantiate the findings of abuse.
3. The IDT reviewed all residents with a history of abusive or inappropriate behaviors to confirm their care plans include proper safety interventions, and psychiatric/psychological referrals if needed to protect other residents from potential abuse.
4. Professional Nurses have been educated on completing assessments, evaluations, behavioral reviews, and on the importance of nursing documentation regarding observations reported and on obtaining detailed witness statements at the time of an incident.
5. Additionally, professional nursing has been educated on documentation regarding incidents, follow-up observations, psychosocial impact, or resident-specific evaluations.
6. Staff have been reeducated on facility policy "Investigation of Allegations of Abuse, Neglect, or the Misappropriation of Resident Property Protocol"
7. NHA/Designee shall audit staff on Abuse prevention policy and procedures twice a week for six weeks and then weekly for an additional month. Results of audit shall be reviewed at Quality Assurance Committee for recommendations
8.Corrective Action Date July 22, 2026

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Observations:

Based on a review of clinical records, facility policy, documentation provided by the facility, and staff interviews, it was determined the facility failed to implement abuse prevention and investigation procedures for one of 24 residents reviewed (Resident 74) following an allegation of resident-to-resident sexual abuse involving Resident 12.

Findings include:

A review of the facility policy titled "Investigation of Allegations of Abuse, Neglect, or the Misappropriation of Resident Property," last reviewed by the facility on March 1, 2026, revealed it is the facility policy to implement residents' rights to the fullest intent of the law. To protect the resident and determine the direction of the investigation, the policy requires facility staff to:

Immediately separate residents and assess for possible injury.

Immediately initiate an investigation and remove the alleged perpetrator.

Arrange for medical attention, including a forensic rape exam for suspected sexual abuse.

Obtain written statements from appropriate individuals on duty at the time of the incident.

Notify the administrator, physician, resident representative, and law enforcement.

Report the incident to the Pennsylvania Department of Health and local Area on Aging within 24 hours.

A clinical record review revealed Resident 12 was admitted to the facility on September 18, 2024, with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).

A review of Resident 12's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 18, 2026, revealed that Resident 12 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 08 through 12 indicates cognition is moderately impaired).

A clinical record review revealed Resident 74 was admitted to the facility on September 8, 2025, with diagnoses including dementia.

A review of Resident 74's quarterly MDS assessment dated March 18, 2026, revealed that Resident 74 was severely cognitively impaired with a BIMS score of 03 (a score of 00 through 07 indicates cognition is severely impaired).

A review of facility-provided documentation, witness statements, and staff interviews revealed that on May 3, 2026, Employees 3 and 4, Nurse Aides (NAs), reported observing Resident 12 with his hands inside Resident 74's brief in the area of Resident 74's genitals, resulting in an allegation of resident-to-resident sexual abuse.

During an interview on May 27, 2026, at 1:20 PM, Employee 4, NA, indicated he was not asked to provide a written statement regarding his observations on May 3, 2026. Employee 4 stated that he was asked to provide information regarding the event on the following workday.

During a telephone interview on May 27, 2026, at 2:20 PM, Employee 3, NA, indicated she was not asked to provide a statement on May 3, 2026, regarding her observations of the incident involving Residents 12 and 74. Employee 3 stated that administration contacted her on a later date to obtain information regarding the event.

During a telephone interview on May 27, 2026, at 2:48 PM, Employee 5, Registered Nurse Supervisor (RNS), indicated that she did not interview or debrief Employee 3 or Employee 4 regarding their observations of the incident. Employee 5 stated that administration requested a statement from her several days after the event occurred.

A clinical record review revealed no documented evidence in either Resident 12's or Resident 74's clinical record that nursing staff completed resident-specific observations, evaluations, assessments, or investigative documentation at the time of the May 3, 2026, incident. Additional review revealed no documented evidence that physicians or resident representatives were notified of the allegation. The clinical records also lacked documented evidence that additional interventions were implemented following the allegation to address Resident 12's behavior or to protect Resident 74 and other residents from further unwanted contact.

During an interview on May 29, 2026, at 10:00 AM, the above information was reviewed with the Nursing Home Administrator (NHA). The NHA was unable to provide documented evidence that the facility fully implemented its abuse investigation and prevention procedures following the May 3, 2026, allegation. Specifically, the facility was unable to provide documented evidence that it immediately initiated and completed a thorough investigation, obtained detailed witness statements at the time of the incident, completed resident evaluations or assessments related to the allegation, notified all required individuals and agencies in accordance with facility policy, or implemented timely interventions to address Resident 12's behavior and ensure ongoing resident safety. The facility was further unable to provide documented evidence that additional protective interventions were implemented following the allegation until Resident 12 was transferred to another nursing unit approximately 16 days later.

Refer F 600

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)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 07/22/2026

1. Facility completed an investigation into the allegation of abuse involving Resident 12 and Resident 74. Facility policy Investigation of Allegations of Abuse, Neglect, or the Misappropriation of Resident Property Protocol implemented, and investigation completed which included conducting interviews and obtaining statements and submitting report and findings to Department of Health, Local Police and Protective Services. Facility investigation found the allegation to be unsubstantiated.
2. The facility has reviewed its comprehensive abuse prevention policies and procedures to ensure it includes the necessary items to explicitly detail the response required to protect alleged victims, ensure thorough investigations, and mandate reporting to state agencies.
3. Professional Nursing has been reeducated on facility protocol to immediately initiate and complete a thorough investigation, obtain detailed witness statements at the time of the incident, complete resident evaluations or assessments related to the allegation, notify all required individuals and agencies in accordance with facility policy, and implement timely interventions to address behavior and ensure ongoing resident safety.
4. Healthcare Personnel have been reeducated on Investigation of allegations of abuse, neglect, or the misappropriation of resident property protocol.
5. The Administrator/designee will review all reported grievances and allegations on a weekly basis to ensure that internal investigations and required reporting protocols are strictly followed.
6. NHA/Designee will audit staff on abuse prevention protocol and procedures twice a week for six weeks and then weekly for an additional four weeks. Results of audits will be reviewed and discussed at Quality Assurance Committee meeting for recommendations.
7. Corrective Action Date: July 22, 2026

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on observations, a review of clinical records, and staff interviews, it was determined that the facility failed to consistently implement preventive interventions to avoid the development of pressure injuries for two of 24 residents reviewed (Residents 18 and 126).

Findings include:

A clinical record review revealed Resident 18 was admitted to the facility on October 15, 2024, with diagnoses that included chronic kidney disease (gradual loss of kidney function) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).

A review of the comprehensive individual care plan revealed Resident 18 had potential for pressure related skin failure related to impaired mobility initiated on October 15, 2024. Interventions implemented to ensure Resident 18 will have intact skin integrity include elevating bilateral lower extremities to keep the resident's heels off the bed or chair surface with pillows.

A physician's order for Resident 18 to be out of bed to Broda chair (a specialized medical wheelchair and recliner used for individuals with severe mobility issues who spend most of the day seated, prioritizing advanced posture support, pressure relief, and fall prevention) with calf bumpers (a soft padded or plastic device that covers prominences on a wheel chair to prevent injury) at all times initiated on July 30, 2025.

A review of Resident 18's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 1, 2026,, revealed that Resident 18 BIMS evaluation (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 13 through 15 indicates cognition is intact) was not completed because the resident was rarely or never understood. A review of section C 1000 Cognitive Skills for Daily Decision Making revealed Resident 18 was severely impaired regarding making decisions for daily life.

During an observation on May 27, 2026, at 11:05 AM Resident 18 was observed sitting outside the Unit 3 nursing station in a Broda chair. The chair's leg rest brackets were exposed and no calf bumpers were applied to the chair as indicated in the physician's orders. There were no observable injuries on Resident 18's bilateral lower extremities at the time of the observation.

During an interview on May 27, 2026, at 11:07 AM Employee 1, Registered Nurse (RN), confirmed that Resident 18's physician's orders for calf bumpers were not applied to the resident's chair.

A clinical record review revealed Resident 126 was admitted to the facility on May 23, 2026, with diagnoses that included dysphagia (difficulty swallowing) and moderate protein-calorie malnutrition (a state resulting from lack of intake or uptake of nutrition that leads to altered body composition).

A review of the baseline care plan revealed Resident 126 had potential for pressure related skin failure related to impaired mobility initiated on May 23, 2026. Interventions implemented to ensure Resident 126's will have intact skin integrity included elevating bilateral lower extremities to keep the resident's heels off the bed or chair surfaces.

A review of Resident 126's admission MDS assessment dated May 25, 2026, revealed that Resident 126 was severely cognitively impaired with a BIMS score of 7 (a score of 00 through 07 indicates cognition is severely impaired).

A physician's order for Resident 126 to be out of bed in a Broda chair with a padded foot buddy board (a single, flat, solid surface that attaches to the front of the wheelchair to support both the user's legs and feet at the same time) and calf bumpers at all times was initiated on May 26, 2026.

During an observation on May 27, 2026, at 11:15 AM Resident 126 was observed in the Unit 3 dining room in a Broda chair. The chair's leg rest brackets were exposed, and no calf bumpers were applied to the chair as indicated in physician's orders. Also, the foot buddy/board utilized to elevate the resident's bilateral legs were not applied to the wheelchair. There were no observable injuries on Resident 126's bilateral lower extremities at the time of the observation.

During an interview on May 27, 2026, at 11:28 AM Employee 2, nurse aide (NA), confirmed that Resident 126's physician's orders for calf bumpers and a foot buddy board were not applied to the resident's chair.

During an interview on May 29, 2026, at 10:00 AM the above information was reviewed with the Nursing Home Administrator (NHA). The facility failed to consistently implement preventive interventions ordered by the physician to avoid the development of pressure injuries for Residents 18 and 126.

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

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

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

Plan of Correction - To be completed: 07/22/2026

1. Resident 18 calf bumpers in place on broda chair as per Physician's order
Resident 126 calf bumpers have been discontinued due to new order for bilateral and foot buddy at all times when out of bed per physician order.
2. Current residents at risk for pressure sores have been audited to ensure all preventative skin interventions in place.
3. Nursing Personnel (RN, LPN, CNAs) have been reeducated on calf bumper protocol and the importance of consistently implementing preventive interventions to avoid the development of pressure injuries.
4. RN Wound Nurse/Designee shall audit five residents three times per week on each floor for one month then weekly for one month to ensure all skin preventative measures in place.
5. Results of audit shall be brought to Quality Assurance Committee for review and recommendations.
6.Corrective action July 22, 2026

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 a review of clinical records, documentation provided by the facility, select facility policy, observations, and resident and staff interviews, it was determined the facility failed to ensure adequate supervision and timely staff assistance for a resident identified as a high risk for falls to prevent a fall (Resident 63) and failed to ensure planned safety interventions were consistently implemented for a resident (Resident 108) for two out of 24 residents reviewed.

Findings include:

Review of the facility's Fall Management Policy and Procedure last reviewed March 1, 2026, indicated that it is the policy of the facility to ensure the resident's environment remains as free from accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevents accidents. A Fall Risk Evaluation will be completed on admission and readmission (to be completed by the admitting nurse), quarterly, with significant change, and annually by the RNAC (registered nurse assessment coordinator), as well as after each fall by the nurse on duty. Resident and, or family education regarding falls and person centered fall prevention strategies will be provided on admission and as needed.

A review of the clinical record revealed that Resident 63 was admitted to the facility on April 25, 2026, with diagnoses that included acute on chronic congestive heart failure (CHF, sudden, severe, worsening of symptoms of compromised heart function such as acute fluid buildup or severe shortness of breath), chronic obstructive pulmonary disease (COPD, lung condition which restricts airflow and makes breathing difficult), benign paroxysmal vertigo (common inner ear issue that causes sudden, brief feelings of spinning triggered by changes in head position, vertigo spells typically last less than one minute and come on suddenly), and atrial fibrillation (irregular heartbeat).

A review of Resident 63's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 1, 2026, revealed that Resident 63 was cognitively intact with a BIMS score of 14 (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 13 through 15 indicates cognition is intact), required partial to moderate assistance (helper does less than half the effort) for toileting hygiene, required supervision or touching assistance to get on and off the toilet or commode, and had no falls in the last six months.

The resident's Fall Risk Evaluation dated April 25, 2026, indicated the resident scored a 20 (a score of 10 or greater indicates a high risk for falls).

A review of Resident 63's current comprehensive care plan initially dated April 25, 2026, indicated the resident had a self care performance deficit due to impaired balance and heart failure. Interventions to improve the resident's current level of function included to ambulate with the assistance of one staff with rolling walker (mobility aid with wheels) and gait belt (strap made of canvas placed around the resident's waste to assist staff to help steady, support, or safely transfer residents who have balance or mobility issues) to and from the bathroom.

A review of a health status note for Resident 63 dated May 20, 2026, at 3:34 PM documented increased shortness of breath and +3 edema (severe pitting edema, which indicates a significant accumulation of excess fluid within body tissues) to both lower extremities. The note documented physician notification and new orders to increase Lasix (a medication used to remove excess fluid from the body) to 40 milligrams by mouth twice daily, administer oxygen at 2 liters per minute as needed, and obtain a Basic Metabolic Panel (BMP, a blood test used to evaluate general health, kidney function, fluid balance, and metabolism) within one week.

A review of nursing documentation dated May 20, 2026, at 10:45 PM revealed staff found the resident lying face down on the floor, partially inside the bathroom doorway. The documentation indicated a Licensed Practical Nurse (LPN) was applying pressure to the resident's head due to significant bleeding. The note described an approximately 12 cm (centimeter) by 12 cm deep laceration (a tear or cut in the skin) with a skin flap located on the top of the head extending toward the forehead. Nursing staff documented repositioning the skin flap, approximating the wound edges, applying Steri-Strips (thin sterile adhesive strips used to assist with wound closure), covering the area with gauze dressings, and maintaining manual pressure and ice application until Emergency Medical Services (EMS) arrived. The note further documented that blood observed on the inside of the bathroom door suggested the resident fell forward and struck her head on the door. Nursing staff notified the physician, obtained an order for emergency room transfer, and notified the resident representative.

A review of hospital emergency department records dated May 21, 2026, revealed the resident reported experiencing dizziness described as vertigo (a sensation of spinning or loss of balance), tripping over her own foot, and falling forward with a head strike. Hospital documentation indicated the resident sustained a head laceration requiring ten staples for closure. The emergency department also diagnosed the resident with acute respiratory failure with hypoxia (a sudden condition in which the lungs cannot adequately deliver oxygen into the bloodstream), resulting in hospital admission.

A review of facility investigative documentation related to the fall revealed the resident reportedly stated at the time of the incident on May 20, 2026, that she knew she was not supposed to get up by herself.

A written witness statement completed by Employee 12, Nurse Aide, documented that the aide assisted the resident to the bathroom, provided privacy, instructed the resident to use the call bell when finished, and reported to nursing staff prior to the fall that the resident was "not herself." Additional facility documentation indicated the resident had been placed on the toilet approximately five minutes before the fall occurred. Although the call bell was documented as being within reach, records indicated it was not activated at the time staff discovered the resident on the floor.

During an interview conducted on May 28, 2026, at 1:40 PM, in the presence of Employee 11, Registered Nurse Supervisor (RNS), Resident 63 stated that she rang the call bell before the fall, but no one responded. The resident stated she believed she had waited long enough, attempted to transfer herself from the toilet, began losing her balance due to vertigo, fell, and then yelled for assistance. The resident stated that some staff members remained with her during toileting while others did not. The resident indicated she did not object to staff remaining with her in the bathroom and stated that she knows staff are busy but at times she waits too long for the call bell to be answered.

During an interview on May 29, 2026, at 10:00 AM, the Director of Nursing confirmed the facility failed to provide the supervision necessary to ensure Resident 63's safety and prevent the avoidable fall.

Review of the facility's policy entitled, "Elopement/Wandering Protocol," last reviewed March 1, 2026, revealed the facility required application of a Wander guard device (an electronic monitoring device used to alert staff when a resident at risk for wandering or elopement approaches an exit) for residents identified as attempting to wander or elope, quarterly reevaluation of the intervention, and maintenance of a resident photograph at the receptionist area for identification purposes.

A review of Resident 108's clinical record revealed that the resident was admitted to the facility on September 7, 2025, with a diagnosis that included vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to parts of the brain, depriving them of oxygen and nutrients) and depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time).

A review of Resident 108's quarterly MDS dated March 17, 2026, revealed the resident was severely cognitively impaired with a BIMS score of 03 (a score of 0 through 7 indicates severe cognitive impairment).

A review of an elopement risk assessment completed on September 7, 2025, identified Resident 108 as being at high risk for elopement. Documentation indicated the resident had a history of wandering in the community prior to facility admission and had required relocation on two occasions before placement in the nursing facility.

A physician order dated September 7, 2025, directed staff to maintain a Wander guard bracelet on the resident's right lower extremity and wheelchair and required staff to verify placement and proper functioning every shift.

Clinical record review for Resident 108 revealed continued evidence of wandering behavior. A nursing progress note dated October 22, 2025, documented the resident wandering through facility hallways and entering and exiting other residents' rooms. A nursing progress note dated January 22, 2026, documented that the resident wandered during nighttime hours.

A review of the May 2026 Task Administration Record (TAR) revealed staff documented on May 28, 2026, at 7:00 AM that Resident 108 was wearing a Wander guard device on the right lower extremity.

However, direct observation conducted on May 28, 2026, at 1:45 PM revealed no Wander guard device present on the resident's right leg or any other extremity. The resident did not have a personal wheelchair present in the room. Employee 7, Licensed Practical Nurse (LPN), confirmed the absence of the device during the observation and was unable to locate the Wander guard within the resident's room. Employee 7 stated that Wander guard devices are not easily removed.

A review of the receptionist's Wander guard monitoring log conducted on May 29, 2026, at 1:25 PM revealed Resident 108 remained listed as requiring Wander guard monitoring; however, no resident photograph was maintained as required by facility policy.

During an interview on May 29, 2026, at 1:30 PM, the Director of Nursing reviewed the above findings and confirmed the facility failed to consistently implement and monitor the resident's planned elopement prevention interventions, including maintenance of the Wander guard device and required identification photograph.

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

28 Pa. Code 211.10 (c) Resident care policies

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

Plan of Correction - To be completed: 07/22/2026

1. Resident 63 has safety interventions in place, which now includes a smart alarm to bed and wheelchair to alert staff of attempts of independent transfer
Resident 108 has wanderguard to RLE and wheelchair checked every four hours for placement
2. Nursing Personnel (RN, LPN, CNA) have been directed to provide assistance in the bathroom to residents with changes in condition and not to leave them alone.
3. Residents with an order for a wanderguard are checked daily each shift and photos are maintained at the front desk as per the policy.
4. Nursing Personnel (RN, LPN, CNA) have been reeducated on Fall Management Policy and Procedure, and timely response to call bells and Wanderguard protocol.
5. DON/Designee to audit bathroom call bells and response time three times per week on all shifts for three weeks and then twice per week on all shifts for one month.
6. ADON/Designee shall audit all residents with an order for a wanderguard three times per week on all shifts for four weeks and then bi-weekly for one month.
RN Charge Nurse/Designee shall conduct call bell audits twice a week on both floors for one month
DON/Designee shall review incident accident reports with IDT team to identify trends and adjust interventions.
7. Results of audits shall be brought to Quality Assurance Committee for review and recommendations.
8.Corrective Action Date July 22, 2026

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 a review of clinical records, select facility policy, observation, and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered per a physician's orders for one resident out of 24 residents reviewed (Resident 123).

Findings include:

A review of the facility's policy titled "Oxygen Administration," last reviewed on March 1, 2026, revealed the purpose of the policy was to provide guidelines for safe oxygen administration. The policy directed staff to check the oxygen delivery system, including the mask, oxygen tank, and humidifier bottle (also known as humidifier reservoir, the container that holds sterile or distilled water through which oxygen passes to add moisture before being delivered to the resident) to ensure they were in good working order and securely fastened. The policy required staff to verify there was an adequate water level in the humidifier bottle so that the water bubbled as oxygen flowed through and to periodically re-check the water level to ensure proper humidification.

A clinical record review revealed that Resident 123 was admitted to the facility on May 21, 2026, with a diagnosis to include respiratory failure (a serious condition that makes it difficult to breathe) with hypoxia (a condition where there is inadequate supply of oxygen to the body's tissues).

A review of Resident 123's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 26, 2026, revealed the resident had moderately impaired cognition 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 through 12 indicates moderate cognitive impairment).

A review of physician's orders dated May 21, 2026, directed that Resident 123 receive oxygen with humidified water at 5.0 liters per minute (L/min) by nasal cannula (a flexible medical tube with two prongs that fit into the nostrils, used to deliver supplemental oxygen), to check oxygen humidification every shift and refill as needed, and directed nightshift staff to fill the humidifier bottle daily.

A review of Resident 123's Treatment Administration Record (TAR) for May 2026 revealed that on May 26, 2026, at 11:00 PM, it was signed off that the humidifier bottle was filled, and on May 27, 2026, at 7:00 AM, it was signed off that the water humification level was checked.

An observation on May 27, 2026, at 11:15 AM revealed the resident was in bed receiving oxygen at 5.0 liters per minute (L/min) via nasal cannula, with no water in the humidifier bottle attached to the oxygen flowmeter. The humidification bottle was dated May 24, 2026.

This observation was confirmed, and humidification water was replaced by Employee 8, a Licensed Practical Nurse, on May 27, 2026, at 11:30 AM.

A follow-up observation on May 29, 2026, at 8:00 AM revealed the resident was in bed receiving oxygen at 5.0 liters per minute (L/min) via nasal cannula, with a quarter of the bottle filled with water that was attached to the oxygen flowmeter. The humidification bottle was dated May 27, 2026.

During an interview with the Director of Nursing on May 29, at 8:30 AM, the above findings were reviewed and confirmed it is the facility's responsibility to ensure oxygen therapy is administered in accordance with the physician's order.

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

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

Plan of Correction - To be completed: 07/22/2026

1. Resident 123 is receiving humidified oxygen as per order.
2. Current residents with an order for humidified oxygen have an adequate supply of water in the humidifier bottle.
3. Professional Nursing has been educated on Oxygen Administration Policy.
4. IPC Nurse/Designee shall audit five residents bi-weekly for one month who have an order for oxygen therapy to ensure the water in the humidifier bottle is adequate as per policy and then weekly for an additional four weeks.
5. Results of the audit shall be brought to Quality Assurance Committee for review and recommendations.
6. Corrective action date: July 22, 2026

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on a review of clinical records, facility policy, and resident and staff interviews, it was determined that the facility failed to comprehensively evaluate, monitor, communicate, and implement appropriate interventions for new onset and worsening pain in accordance with physician orders and facility policy for one of 24 residents reviewed (Resident 41).

Findings include:

Review of the facility's "Pain Assessment and Management" policy, last reviewed March 1, 2026, revealed that the purpose of the policy was to help staff identify resident pain and to help develop interventions that are consistent with resident goals. The policy indicated the facility was to conduct a comprehensive pain assessment upon admission to the facility and whenever a resident experienced new pain or worsening pain.

Clinical record review revealed that Resident 41 was admitted to the facility on May 13, 2026, with a diagnosis of diabetes (medical condition in which the body is unable to properly regulate blood sugar levels) and fractures of the mid-back area. A review of Resident 41's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 18, 2026, revealed that Resident 41 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 through 12 indicates moderate cognitive impairment). The MDS also indicated that over the past 5 days, the resident experienced a moderate degree of pain (pain levels between 4 and 6). A numerical pain scale ranging from 0 to 10 is commonly used to assess pain intensity, with 0 representing no pain, 1 through 3 representing mild pain, 4 through 6 representing moderate pain, and 7 through 10 representing severe pain.

Review of the resident's admission pain evaluation revealed documentation indicating the resident was able to respond appropriately and reported no pain during the five-day period prior to admission.

Review of physician orders initiated upon admission on May 13, 2026, revealed an order for acetaminophen (a non-opioid pain-relieving medication) to be administered for resident-reported pain levels of 1 through 3, consistent with mild pain.

Review of the May 2026 Medication Administration Record (MAR) revealed documented pain assessments on May 14, May 21, May 22, and May 28, 2026, indicating the resident experienced pain that had not been identified on admission. Despite evidence of new onset pain, there was no documented evidence the facility completed a comprehensive pain re-evaluation as required by facility policy.

Clinical record review revealed the resident reported a pain level of 4 on May 21 and May 22, 2026, indicating moderate pain that exceeded the parameters of the existing physician order, which only addressed mild pain levels of 1 through 3. There was no documented evidence that the physician was notified of the resident's increased pain level, no evidence the resident's pain management regimen was re-evaluated, and no evidence new or revised physician orders were obtained to address the resident's moderate pain.

During an interview conducted on May 28, 2026, at 1:00 PM, and again on May 29, 2026, at 8:45 AM, Resident 41 reported experiencing pain in the neck and mid-back region and rated the pain as an 8 on a 0-to-10 pain scale, indicating severe pain. The resident stated staff occasionally administered "something for pain, but it is not effective".

Review of Resident 41's comprehensive care plan failed to identify the resident's pain, the location of the pain, or interventions utilized to monitor or alleviate the pain. Documentation reflected pain-related information was not added to the care plan until after surveyor inquiry.

It was not until after surveyor notification on May 29, 2026, at approximately 9:15 AM that the facility re-evaluated the resident's pain and obtained additional physician orders, including a stronger pain medication, to address pain levels greater than 3.

During an interview on May 29, 2026, at 9:30 AM, the Director of Nursing was unable to provide evidence that the facility had timely re-evaluated the resident's new onset pain in accordance with facility policy, notified the physician of pain levels exceeding the resident's current treatment parameters, or obtained timely physician intervention to address the resident's ongoing pain complaints.

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

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

Plan of Correction - To be completed: 07/22/2026

1. Resident 41 pain had his pain managed effectively with pain management prior to discharge to the community.
2. New admissions with new or worsened pain identified on their pain assessment will have their pain care plan reviewed to ensure it identifies the location of the pain, interventions utilized to monitor or alleviate the pain.
3. Nursing Personnel have been educated on Pain Management Policy.
4. RNAC/Designee will audit careplans weekly on residents with new or worsening indications of pain based on the pain assessment for four weeks, and then every other week for another month.
5. Results of audits will be brought to Quality Assurance Committee for review and recommendations.
6. Corrective Action Date: July 22, 2026

483.60(d)(3) REQUIREMENT Food in Form to Meet Individual Needs:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(3) Food prepared in a form designed to meet individual needs.

Observations:

Based on a review of clinical records, review of select facility policy, documentation provided by the facility, and staff interview, it was determined the facility failed to ensure that food was served in a form to meet the individual needs of one of 24 residents reviewed. (Resident 94)

Findings include:

Review of the facility's Thickened Liquids and Pureed Food Policy last reviewed March 1, 2026, indicated that the diet order must include the dysphagia (difficulty swallowing) level of solid foods and the liquid consistency. Never serve regular texture food to a resident ordered a pureed diet. When in doubt about a diet order, verify before serving. The Key Safety Rule is to always serve the correct texture and observe the resident while eating to reduce the risk of choking and aspiration (accidentally breathing food or liquid into the airway or lungs instead of swallowing them).

A review of the clinical record revealed that Resident 94 was admitted to the facility on January 7, 2026, with diagnoses that included congestive heart failure (CHF-the heart muscle becomes too weak or stiff to pump blood efficiently) and oropharyngeal dysphagia (swallowing problems occurring in the mouth and, or throat).

A physician order initially dated March 24, 2026, documented an order for a puree diet (foods that are blended, whipped, or mashed into a smooth, lump-free, and uniform texture that reduces the risk of choking and aspiration) no added salt regular thin liquid consistency diet.

A review of Resident 94's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 3, 2026, revealed that Resident 94 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 through 12 indicates moderately cognitively impaired) and required setup or clean-up assistance for meals (the helper sets up or cleans up and the resident completes the activity with the helper assisting only prior to or following the activity).

A health status note dated May 14, 2026, documented that the resident was sitting at the nurses station eating a peanut butter and jelly sandwich. The resident started coughing and Employee 9 Licensed Practical Nurse (LPN) and Employee 10 Registered Nurse (RN) assessed the resident. The resident had a piece of sandwich in her throat. Employee 9 LPN stood up the resident while Employee 10 RN did Heimlich maneuver (first aid technique for someone who is choking because food or another swallowed object is obstructing his or her airway. Using an upward abdominal thrust, the Heimlich maneuver compresses the lungs and forces air up into the windpipe until the object causing the choking is ejected from the throat). The sandwich piece popped out. The physician and resident representative were notified.

An incident note dated May 14, 2026, noted that the resident was able to breathe and talk without difficulty following the incident. Lung sounds were clear and vital signs (measurements of the body's most basic functions and include body temperature, pulse rate, rate of breathing, and blood pressure) were stable. Staff were to continue to monitor the resident's breathing and lung sounds.

Review of documentation provided by the facility dated May 14, 2026, at 12:30 AM revealed that Resident 94 was provided with a peanut butter and jelly sandwich as a snack by Employee 9 LPN) which was not a pureed food item as required based on the resident's prescribed physician diet order. Employee 9 LPN failed to check the resident's diet order prior to providing the sandwich. Staff education was initiated following the incident related to checking for the appropriate diet consistency before providing food, snacks, or drinks at any time to residents. Employee 9 LPN who provided the sandwich was disciplined and reeducated. The physician was notified and a chest Xray was ordered. The physician also ordered to monitor the resident's temperature and lung sounds every shift for 72 hours. The facility will provide the resident a puree peanut butter and jelly sandwich for the resident nightly.

Interview with the Nursing Home Administrator (NHA) on May 28, 2026, at 1:00 PM confirmed the facility failed to follow Resident 94's physician ordered diet to ensure an appropriate snack in the correct form was provided to the resident. The NHA confirmed the facility failed to provide a peanut butter and jelly sandwich in a form to meet Resident 94's needs for safe swallowing to prevent a choking episode.

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

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

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

Plan of Correction - To be completed: 07/22/2026

1. Resident 94 has been discharged.
2. Current residents with an order for a pureed diet are receiving the correct diet consistency level.
3. Educational posters have been placed in dining room and nurse's station on diet consistently levels.
4. Healthcare personnel have been reeducated on Thickend Liquid and Pureed food policy.
5. DON/Designee shall audit resident meals/snacks to ensure residents are receiving the correct diet consistency and level as per Physician order three times per week for one month and then twice a week for an additional four weeks.
6. Results of the audits shall be brought to Quality Assurance Committee for review and recommendations.
7.Corrective Action Date: July 22, 2026

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement