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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MEADOWCREST REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are 110 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.


MEADOWCREST REHABILITATION & HEALTHCARE 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 Survey in response to five complaints completed April 30, 2025, it was determined that Meadowcrest Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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.

§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:
Based on review of clinical records and resident and staff interviews, it was determined that the facility failed to the notify resident representative and/or medical provider of a change in condition or care for three of ten residents (Resident R41, R100, and R143).

Findings include:

The "Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual," which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:
13 - 15: cognitively intact
8 - 12: moderately impaired
0 - 7: severe impairment

Review of the clinical record indicated Resident R41 was admitted to the facility on 1/10/25.

Review of Resident R41's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/16/25, included diagnoses of cirrhosis (chronic damage leading to scarring and failure) of the liver and hip fracture.

Review of Resident R41's demographic profile indicated his son as his emergency contact.

Review of a progress note dated 2/2/25, at 2:15 a.m. indicated, "C/O (complained of) being cold. Has multiple blankets on." "States he is unwilling to go hospital, despite reporting being sick all day."

Review of a progress note dated 2/2/25, at 3:30 a.m. indicated, "Continues to c/o being cold." "Requesting prn oxycodone. Given 0330. States it helps him relax and sleep."

Review of a progress note dated 2/2/25, at 6:08 a.m. indicated, "Called by CNA (nurse aide) doing rounds 0510 (5:10 a.m.). Resident without pulse BP (blood pressure) or respiration, neg vs (vital signs) on recheck, pupils fixed and dilated. Pronounce (5:10 a.m.). Son notified 0515 (5:15 a.m.)., [Physician] notified 0600 (6:00 a.m.). Waiting for family to return call with name of mortuary service."

Review of progress notes failed to reveal a notification to the provider of Resident R41 feeling unwell "all day" and of excessive feelings of cold.

Review of the clinical record indicated Resident R100 was admitted to the facility on 4/13/21.

Review of Resident R100's MDS dated 1/17/25, included diagnoses of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior) and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease).

Review of the most recent BIMS assessment completed on 11/26/24, revealed a BIMS score of "05."

Review of Resident R100's demographic profile indicated her sister as her emergency contact, legal guardian, and responsible party.

Review of a physician order dated 2/10/25, indicated Resident R100 had a new order for a pureed diet. Resident R100 had previously had a mechanical soft diet.

Review of a progress note dated 2/12/25, at 9:07 p.m. indicated, "Residents sisters were in throughout the day. Sister has many questions concerning what resident ' s medications, when started, and why she is taking them. Questioning reason for changing to a pureed diet and why this sister did not receive a phone call to inform her of the change."

Review of the clinical record indicates resident R143 was admitted to the facility on 4/7/25.

Review of the facility diagnosis list included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), lung cancer, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life) without behavioral disturbance.

Review of Resident R143's demographic profile indicated her granddaughter as her emergency contact, legal guardian, and responsible party.

Review of a physician order dated 4/8/25, indicated, "Send to [hospital emergency room] for evaluation due to AMS (altered mental status), wandering, refusing to take medications."

Review of a progress note dated 4/8/25, at 8:49 a.m. indicated, "As this writer approached the nurses station as the resident was going out the side door, the doctor came. She walked up to the physician, became verbally and physically aggressive. at that time, the doctor stated to send the patient to the emergency department as she is exhibiting behavior trying to exit the building and for her safety she needed to be in a locked or protected unit. He ordered her to go to [hospital] as he said that [hospital] has a good psych department."

Review of a progress note dated 4/8/25, at 5:14 p.m. indicated, "[hospital] called again and this writer spoke with another nurse in re: resident reason for being sent to their hospital. I explained and once again, the nurse stated "you have to fill out a 302 paper and she is a resident at your facility and I ' m calling the Health Department" and hung up."

Review of family submitted information dated 4/9/25, indicated that the faciltiy transferred Resident R143 to the hospital without family notification.

Review of Resident R143's progress notes failed to reveal a notification to Resident R143's emergency contact regarding the transfer to the hospital.

During an interview on 4/30/25, at approximately 12:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify the resident representative and/or medical provider of a change in condition or care for three of ten residents.

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

28 Pa. Code 201.29(d) Resident rights.

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

28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 06/11/2025

Residents 41,100, and 143 had no negative outcome for not meeting requirement of notification of change in residents condition.
The facility will complete a 30-day lookback at any residents with a change in condition to ensure required notifications were met.
DON/designee will provide education to licensed staff on policy for notification of change in conditions.
DON/designee will audit five times a week for 2 weeks and monthly times 1 month. For changes in condition and notifications. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met

483.95 REQUIREMENT Training Requirements:

§483.95 Training Requirements
A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment as specified at § 483.71. Training topics must include but are not limited to-

Observations:
Based on review of facility documentation and staff interviews, it was determined that the facility failed to develop, implement, and maintain an effective training program, including additional training topics based on the resident population, outcome of the facility assessment, or non-common procedures for two of four Nurse Aides (NA) (Employee E1 and E2).

Findings include:

Review of information published by the American Cancer Society dated 11/22/19, indicated, "Chemotherapy drugs are considered to be hazardous to people who handle them or come into contact with them. For patients, this means the drugs are strong enough to damage or kill cancer cells. But this also means the drugs can be a concern for others who might be exposed to them." "Flush the toilet twice after you use it. Put the lid down before flushing to avoid splashing. If possible, you may want to use a separate toilet during this time. If this is not possible, wear gloves to clean the toilet seat after each use."

Review of the "Facility Assessment" dated 1/4/25, indicated in the previous twelve months, the facility had not cared for residents that received chemotherapy.

Review of the facility policy, "Staff Development Program" dated 1/4/25, indicated one of the primary purposes of the facility's in-service training program is to provide up-to-date information that will assist in providing quality care.

Review of the clinical record indicated Resident R96 was admitted to the facility on 4/1/25.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/5/25, included diagnoses of osteoporosis (condition when the bones become brittle and fragile), muscle weakness, and high calcium in the blood.

Review of a physician's note dated 4/8/25, indicated that awaited lab results indicated Resident R96 had been diagnosed with B-cell lymphoma (a group of cancers that attack the immune system).

Review of a physician order dated 4/25/25, indicated, "FLUSH TOILET TWICE WITH LID DOWN."

Review of Resident R96's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) failed to include information related to flushing the toilet after use by Resident R96.

During an observation of 4/29/25, at 9:59 a.m. of Resident R22's room revealed that it shared a restroom with Resident R96's room.

During an observation of the shared restroom on 4/29/25, at 10:00 a.m. revealed the commode was not equipped with a lid. Above the commode was a handwritten sign stating to flush the toilet twice with the lid closed.

During an interview on 4/30/25, at 10:45 a.m. NA Employee E1 confirmed that Resident R22 and R96 both use the commode. When asked about closing the sign indicating closing the lid, NA Employee E1 stated she didn't really understand the sign as the lid is always closed and they usually only flush once since it takes a long time to refill. At this time, NA Employee E1 motioned to the lid of the reservoir tank.

During an interview on 4/30/25, at 10:52 a.m. NA Employee E2 when asked about closing the sign indicating closing the lid, NA Employee E2 stated they were just told about his two days ago and confirmed that she did not understand how to close the lid when there wasn't a lid to close. At this time, both NA Employees E1 and E2 confirmed the facility did not provide education to them on how to appropriately dispose of Resident R96's waste and how to prevent possible exposure of chemotherapy drug waste to Resident R22.

During an interview on 4/30/25, at approximately 12:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the care of chemotherapy patients had not been a common requirement in the facility, confirmed that the facility did not provide education to staff on the appropriate way to prevent possible exposure of chemotherapy drug waste to other residents, and further confirmed that the facility failed to develop, implement, and maintain an effective training program, including additional training topics based on the resident population, outcome of the facility assessment, or non-common procedures for two of four nurse aides.

28 Pa. Code 201.19(7) Personnel policies and procedures.

Plan of Correction - To be completed: 06/11/2025

Resident R96 has discharged from the facility. DON educated on the requirement to provide up to date education to direct staff to ensure that they can provide quality care when a new process is implemented. DON educated the 2 CNAs at the time of survey.
There are no other residents receiving chemotherapy agents in the facility at this time.
Direct Care staff will be retrained on appropriate care when a person is receiving a chemotherapy agent.
The DON/Designee will audit five times a week for two weeks and then monthly times two months to ensure orders for equipment and treatments are followed. The results of these audits will be reported to the Facility's Monthly QAPI meeting until compliance is met.

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

Observations:
Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for four of eight residents (Resident R2, R9. R12, and R31).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2024, indicated that Section C: Cognitive Patterns, Question C0100 "Should Brief Interview for Mental Status Be Conducted?" (BIMS) should be coded as "0" if the resident is rarely/never understood, or it should be coded "1", and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 "Should Resident Mood Interview Be Conducted?" should be coded as "0" if the resident is rarely/never understood, and or it should be coded "1", and the assessment should be completed if the resident is at least sometimes understood.

Resident R2 had an MDS completed on 2/1/25. Review of Section B: Hearing, Speech, and Vision indicated Resident R2 was not in a persistent vegetative state/no discernible consciousness. The remainder of the questions in this section were documented as "Not Assessed." Review of Sections C: Cognitive Patterns and Section D: Mood, BIMS and Resident Mood Interview indicated all questions were documented as "Not Assessed."

Resident R9 had an MDS completed on 3/11/25. Review of Section B: Hearing, Speech, and Vision indicated Resident R9 was not in a persistent vegetative state/no discernible consciousness. The remainder of the questions in this section were documented as "Not Assessed." Review of Sections C: Cognitive Patterns and Section D: Mood, BIMS and Resident Mood Interview indicated all questions were documented as "Not Assessed."

Resident R12 had an MDS completed on 1/21/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R29 is "usually understood." Review of Sections C: Cognitive Patterns and Section D: Mood, revealed for the BIMS and Resident Mood Interview all questions were documented as "Not Assessed."

Resident R31 had an MDS completed on 1/17/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R31 is "understood." Review of Sections C: Cognitive Patterns and Section D: Mood, revealed for the BIMS and Resident Mood Interview all questions were documented as "Not Assessed."

During an interview on 4/30/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for four of eight residents.

28 Pa. Code: 211.5(f) Clinical records.

Plan of Correction - To be completed: 06/11/2025

Residents 2, 9,12, and 31 had no negative outcome for not meeting the requirements for proper coding of mood/cognition on the MDS as not assessed. The RNAC that had charted the errors is no longer employed at the Facility. The new RNAC has been provided education by the Regional VP of Case Management.
Review of current residents MDS of section c, and D reviewed for accuracy.
Registered Nurse Assessment Coordinator or designee will audit Section C: Cognitive
Patterns and Section D: Mood of Minimum Data Set for three resident's weekly times two weeks and monthly times two months.
The results of these audits will be reported to the Facility's Monthly QAPI meeting until compliance is met.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:
Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for three of eight residents (Residents R20, R27, and R96).

Findings include:

Review of facility's policy "Comprehensive Assessments and Care Delivery Process" dated 1/4/25, indicated comprehensive assessments, care planning, and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions.

Review of the clinical record revealed that Resident R20 was admitted to the facility on 7/11/17.

Review of Resident R20's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/31/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration).

Review of a physician order dated 12/25/19, indicated Resident R20 received Lexapro (an antidepressant medication) 20 milligrams (mg) at bedtime related for depression.

Review of a physician order dated 10/11/23, indicated Resident R20 received Aripiprazole (an antipsychotic medication) 2.5 mg per day related to bipolar disorder.

Review of a physician order dated 2/28/24, indicated Resident R20 received Wellbutrin XL (an antidepressant medication) 150 mg per day related for depression.

Review of Resident R20's current care plan, most recently reviewed 4/9/25, failed to reveal a plan of care developed with goals and interventions related to the use of antidepressant and antipsychotic medications.

Review of the clinical record revealed that Resident R27 was admitted to the facility on 3/26/25.

Review of the Admission Assessment dated 3/27/25, indicated Resident R27 was admitted with pressure ulcers (localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device) on his left and right heels.

Review of Resident R27's MDS dated 3/29/25, included diagnoses of metabolic encephalopathy (alteration in consciousness caused by a chemical imbalance affecting the brain) and muscle weakness. Review of Section M: Skin Conditions indicated the presence of a Stage III (full-thickness skin loss) pressure ulcer.

Review of Resident R27's care plan initiated 3/27/25, revealed a plan of care developed for the risk that Resident R27 may develop an alteration of skin integrity, but with no plan of care developed with goals and interventions related to Resident R27 having an actual pressure ulcer.

Review of the clinical record indicated Resident R96 was admitted to the facility on 4/1/25.

Review of the MDS dated 4/5/25, included diagnoses of osteoporosis (condition when the bones become brittle and fragile), muscle weakness, and high calcium in the blood. Review of Section C: Cognitive Patterns revealed that Resident R96 had no cognitive deficits.

During an interview and observation on 4/29/25, at 10:20 a.m., Resident R96 was observed to have a medicine cup with a a visibly wet pill in it. Resident R96 stated that it takes a long time for her to get her medication down, so she takes them one at a time.

Review of Resident R96's care plan initiated 4/1/25, failed to reveal a plan of care developed for the self-administration of medication.

During an interview on 4/30/25, at approximately 12:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that a comprehensive resident care plan was complete for resident care needs for three of eight residents.

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

Plan of Correction - To be completed: 06/11/2025

Residents 20, 27, and 96 comprehensive careplans were updated to reflect current diagnosis, medications and treatments
Review of current residents careplans reviewed for accuracy.
DON to educate Licensed staff on facility comprehensive care plan policy.
DON or designee will audit five residents weekly times two weeks and monthly times two months residents careplans for accuracy.
The results of these audits will be reported to the Facility's Monthly QAPI meeting until compliance is met

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

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.

§483.25(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 review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of four residents (Resident R27).

Findings include:

Review of facility's policy, "Prevention of Pressure Ulcers/Injuries" dated 1/4/25, indicated for staff to review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable.

Review of the clinical record revealed that Resident R27 was admitted to the facility on 3/26/25.

Review of the Admission Assessment dated 3/27/25, indicated Resident R27 was admitted with pressure ulcers on his left and right heels.

Review of Resident R27's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 3/29/25, included diagnoses of metabolic encephalopathy (alteration in consciousness caused by a chemical imbalance affecting the brain) and muscle weakness. Review of Section M: Skin Conditions indicated the presence of a Stage III (full-thickness skin loss) pressure ulcer.

Review of Resident R27's care plan initiated 3/27/25, revealed a plan of care developed for the risk that Resident R27 may develop an alteration of skin integrity, but with no plan of care developed with goals and interventions related to Resident R27 having an actual pressure ulcer.

Review of a physician order dated 3/28/25, through 4/2/25, indicated to cleanse the left heel wound with wound cleanser then apply Alginate dressing (wound dressing derived from seaweed) and border gauze.

Review of a physician order dated 4/3/25, indicated to cleanse the left heel wound with wound cleanser, apply medihoney (medical honey used as an antimicrobial) to wound base, then apply alginate dressing and border gauze.

Review of Resident R27 ' s treatment administration record from 3/28/25, through 4/30/25, revealed no documentation of refusals of dressing changes and revealed the following dates without wound treatment documented as completed: 3/28/25, 4/2/25, 4/9/25, 4/13/25, 4/25/25, and 4/27/25.

Review of Resident R27 ' s progress notes failed to reveal documentation of a reason for the dressings not to have been completed.

During an interview on 4/30/25, at approximately 12:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer for one of four residents.

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

Plan of Correction - To be completed: 06/11/2025

Resident R27 was assessed, and order validated that current order in place for treatment of pressure ulcer is correct
Facility residents with current wounds were audited to ensure appropriate and current order in place for treatment of wound.
Don, or designee will educate licensed staff on wound treatment and following physicians orders policy, and verifying orders and care plans for accuracy. Licensed staff will also be educated on charting with documentation of refusals.
DON, or designee will conduct an audit to ensure that treatment orders are being followed, and dressing change/assessments are being completed per physicians orders weekly times 2 weeks, then monthly times 2 months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met

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 facility documentation and staff interviews, it was determined that the facility failed to provide a safe environment for one of two residents (Resident R22).

Findings include:

Review of information published by the American Cancer Society dated 11/22/19, indicated, "Chemotherapy drugs are considered to be hazardous to people who handle them or come into contact with them. For patients, this means the drugs are strong enough to damage or kill cancer cells. But this also means the drugs can be a concern for others who might be exposed to them." "Flush the toilet twice after you use it. Put the lid down before flushing to avoid splashing. If possible, you may want to use a separate toilet during this time. If this is not possible, wear gloves to clean the toilet seat after each use."

Review of the "Facility Assessment" dated 1/4/25, indicated in the previous twelve months, the facility had cared for zero residents that received chemotherapy.

Review of the clinical record indicated Resident R22 was admitted to the facility on 3/20/25.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/26/25, included diagnoses of urinary tract infection and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).

Review of the clinical record indicated Resident R96 was admitted to the facility on 4/1/25.

Review of the MDS dated 4/5/25, included diagnoses of osteoporosis (condition when the bones become brittle and fragile), muscle weakness, and high calcium in the blood.

Review of a physician ' s note dated 4/8/25, indicated that awaited lab results indicated Resident R96 had been diagnosed with B-cell lymphoma (a group of cancers that attack the immune system).

Review of a physician order dated 4/25/25, indicated, "FLUSH TOILET TWICE WITH LID DOWN every shift for CHEMO (chemotherapy, drug treatment that uses powerful chemicals to kill fast-growing cells in the body)."

Review of Resident R96's Kardex (document that outlines the patients ' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) failed to include information related to flushing the toiled after use by Resident R96.

During an observation of the shared restroom on 4/29/25, at 10:00 a.m. revealed the commode was not equipped with a lid. Above the commode was a handwritten sign stating to flush the toilet twice with the lid closed.

During an interview on 4/30/25, at 10:45 a.m. NA Employee E1 confirmed that R96 did not use the common restroom, but did confirm that Resident R22 and R96 both use the commode. When asked about the sign indicating closing the lid, NA Employee E1 stated she didn ' t really understand the sign as the lid is always closed and they usually only flush once since it takes a long time to refill. At this time, NA Employee E1 motioned to the lid of the reservoir tank.

During an interview on 4/30/25, at 10:52 a.m. NA Employee E2 when asked about closing the sign indicating closing the lid, NA Employee E2 stated they were just told about his two days ago and confirmed that she did not understand how to close the lid when there wasn ' t a lid to close. At this time, both NA Employees E1 and E2 confirmed the facility did not provide education to them on how to appropriately dispose of Resident R96 ' s waste and how to prevent possible exposure of chemotherapy drug waste to Resident R22.

During an interview on 4/30/25, at approximately 12:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide a safe environment for one of two residents.

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

28 Pa. Code 201.29(a)(c)(d) Resident rights.

Plan of Correction - To be completed: 06/11/2025

Resident R96, Care plan, Kardex, and equipment updated to reflect correct treatment can be completed for the resident. Resident has discharged from the facility.
There are no current residents receiving chemotherapy agents in the facility currently. A review of current residents with special needs to ensure appropriate careplans, Kardex and equipment are in place.
DON or designee will educate Nursing staff including CNAs on the appropriate procedures when a resident is receiving chemotherapy agents while at the facility. Appropriate equipment available should we have a new resident that is receiving chemotherapy.
The DON/Designee will audit five times a week for two weeks and then monthly times two months to ensure orders for equipment and treatments are followed. The results of these audits will be reported to the Facility's Monthly QAPI meeting until compliance is met.

§ 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.

Plan of Correction - To be completed: 06/11/2025

The residents had no negative outcome for not meeting the minimum of one LPN per 25 residents on day shift, 1 LPN per 30 residents on the evening shift 1 LPN to 40 residents on the night shift.
The facility is attempting to hire additional staff, hold daily staffing meetings to track staffing and added additional agencies to utilize for staffing needs.
DON/designee will provide the Staffing Coordinator/HR with re-education on the Pennsylvania staffing requirements for ratios.
Staffing coordinator/designee will audit the ratios five times weekly for 2 weeks and monthly times two month. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met

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