Meadow View Nursing Center

F-F623 on December 31, 2024.

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

28 Pa. Code 201.18(b)(3) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Level of Harm - Minimal harm or potential for actual harm 46994

Residents Affected - Few Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident and/or the resident's representative at the time of a transfer for three of 43 residents reviewed (Residents 3, 45, 93). This deficiency was cited as past noncompliance.

Findings include:

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 29, 2024, indicated that the resident had moderate cognitive impairment, required assistance from staff for personal care needs, and had diagnosis that included a displaced trimalleolar fracture of the left lower leg (fracture in the ankle joint on the left leg).

A physician's order note for Resident 3, dated November 19, 2024, at 5:17 p.m., revealed that the resident had fallen in her room and had an obvious left ankle deformity. She was transferred to the emergency room for evaluation and treatment.

There was no documented evidence that a bed-hold notice was provided to Resident 3 or her responsible party.

A significant change MDS assessment for Resident 45, dated November 25, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care tasks, and had diagnoses that included atrial fibrillation (irregular heartbeat), high blood pressure, right femur fracture, asthma, and chronic obstructive pulmonary disease.

A nursing note for Resident 45, dated November 14, 2024 at 3:43 a.m., revealed that the resident had a fall, and her right leg was shortened and externally rotated. The resident was transported to the local hospital.

There was no documented evidence that a bed-hold notice for Resident 45 was provided to the resident's representative.

A significant change MDS assessment for Resident 93, dated October 24, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care tasks, had an unstageable pressure ulcer (full-thickness pressure injury involving tissue damage and death) a venous ulcer (ulcers caused by problems with blood flow in the leg veins), and had diagnoses that included peripheral vascular disease (a disease causing poor blood circulation to lower limbs) and diabetes.

A nursing note for Resident 93, dated October 4, 2024, revealed that the resident was transported to the hospital.

There was no documented evidence that a bed-hold notice for Resident 93 was provided to the resident's representative.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Interview with the Nursing Home Administrator on February 4, 2025, at 10:58 a.m. confirmed that the facility did not provide bed-hold notices to the above residents and/or their representative when the residents were Level of Harm - Minimal harm or transferred to the hospital. The Nursing Home Administrator indicated that they had identified the issue of not potential for actual harm providing bed-hold notices to residents and/or their representative on November 24, 2024.

Residents Affected - Few Following the identification on November 24, 2024, that they were not providing the bed-hold notices to the resident and/or the resident's representative when the resident was transferred to the hospital, the facility's corrective actions included:

Education was provided to staff regarding the required bed-hold notice that was to be given to the resident and/or the resident's representative when the resident was transferred to the hospital.

Audits were started on all residents that were transferred to the hospital.

The results of these audits will be brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary.

Review of the facility's corrective actions and interviews with staff regarding their re-education revealed that

they were in compliance with

F-F625 on December 31, 2024.

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

28 Pa. Code 201.18(b)(3) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46994 potential for actual harm Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff Residents Affected - Some interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for nine of 43 residents reviewed (Residents 3, 9, 12, 18, 45, 58, 85, 88, 131).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the intent of Section N was to record the number of days, during the seven days of the assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Sections N0145B antianxiety, N0415F Antibiotic, N0415G Diuretic, N0415H Opioid (narcotic medications used to treat pain), and N0415K anticonvulsant medications were to be coded if the resident took the medication during the seven-day look-back period. Section O0110J1 (Dialysis) was to be coded if the resident received dialysis services. Section O0110K (hospice care) was to be coded if the resident received hospice services.

A significant change MDS assessment for Resident 3, dated November 29, 2024, indicated that the resident had moderate cognitive impairment, required assistance from staff for personal care needs, and had diagnosis that included a displaced trimalleolar fracture of the left lower leg (fracture in the ankle joint on the left leg). Section N0415F-Antibiotic indicated that the resident did not receive any antibiotics during the seven-day look-back period.

Physician's orders for Resident 3, dated November 26, 2024, indicated that the resident was to receive 4.5 grams of piperacillin (an antibiotic) intravenously (into a vein) every six hours for seven days. Review of the Medication Administration Record (MAR) for Resident 3, dated November 2024, revealed that the resident did receive piperacillin during the seven-day look-back period.

Interview with the Registered Nurse Assessment Coordinator on February 7, 2025, at 8:30 a.m. confirmed that Resident 3's MDS, dated [DATE REDACTED], was inaccurately coded regarding antibiotics.

A quarterly MDS assessment for Resident 9, dated January 30, 2025, revealed that the resident was cognitively intact, required assistance from staff for personal care needs, and had diagnoses that included coronary artery disease. Section N0415H (Opioid) indicated that the resident received an opioid during the seven-day look-back period.

Review of the MAR for Resident 9, dated January, 2025, revealed that the resident did not receive opioids

during the seven-day look-back period.

Interview with the Registered Nurse Assessment Coordinator on February 7, 2025, at 8:30 a.m. confirmed that Resident 3's MDS, dated [DATE REDACTED], was inaccurately coded regarding opioid medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 A quarterly MDS assessment for Resident 12, dated January 27, 2025, revealed that the resident was cognitively intact, independent with personal care needs, and had diagnoses that included diabetes. Section Level of Harm - Minimal harm or N0415H (Opioid) indicated that the resident did not receive an opioid during the seven-day look-back period. potential for actual harm Physician's orders for Resident 12, dated August 1, 2024, included an order for the resident to receive 50 Residents Affected - Some milligrams of Tramadol (an opioid) every 12 hours as needed for pain. Review of the MAR for Resident 12, dated January 2025, revealed that the resident received Tramadol during the seven-day look-back period.

Interview with the Registered Nurse Assessment Coordinator on February 7, 2025, at 8:30 a.m. confirmed that Resident 12's MDS, dated [DATE REDACTED], was inaccurately coded regarding opioid medication.

A quarterly MDS assessment for Resident 18, dated December 10, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included dementia, high blood pressure, and stroke. Section N0415H (Opioid) indicated that the resident received an opioid medication during the assessment period, and Section O0110K (Hospice care) indicated that hospice services were not received.

Physician's orders for Resident 18, dated July 15, 2024, included an order for the resident to receive hospice services from the facility's contracted hospice provider. Physician's orders for Resident 18, dated August 30, 2024, included an order for the resident to receive 0.5 milliliters of morphine sulfate (opioid) every two hours as needed for pain. A review of the December 2024 MAR revealed that the medication was not administered

during the seven-day look-back period.

Interview with the Director of Nursing on February 5, 2025 at 12:25 p.m. confirmed that the quarterly MDS assessment for Resident 18 was inaccurately coded regarding opioid medication and hospice services.

A significant change MDS assessment for Resident 45, dated November 25, 2024, revealed that the resident was cognitively intact, required assistance from staff for her daily care needs, required oxygen therapy, and had diagnoses that included atrial fibrillation (irregular heartbeat), high blood pressure, right femur fracture, asthma, and chronic obstructive pulmonary disease. Section N0415F (Antibiotic) and N0415H (Opioid) revealed that the resident received antibiotic and opioid medications during the look-back period.

A review of Resident 45's MAR for November 2024 revealed that the resident did not receive an antibiotic or opioid medication during the seven-day look-back period.

Interview with the Nursing Home Administrator on February 4, 2025, at 1:18 p.m. confirmed that Residents 45's significant change MDS assessment was inaccurately coded regarding antibiotic and opioid medications.

A quarterly MDS assessment for Resident 58, dated January 8, 2025, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included end-stage renal disease (disease that affects kidney function) and dependence on renal dialysis. Section O0110J1 (Dialysis) revealed that the resident did not receive dialysis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Physician's orders for Resident 58, dated July 15, 2024, included an order for the resident to receive dialysis

on Monday, Wednesday, and Friday. Review of Resident 58's clinical record revealed documentation that Level of Harm - Minimal harm or the resident received dialysis services during the assessment period. potential for actual harm

Interview with the Registered Nurse Assessment Coordinator on February 5, 2025, at 2:30 p.m. confirmed Residents Affected - Some that Resident 58's quarterly MDS assessment was inaccurately coded regarding dialysis.

A quarterly MDS assessment for Resident 85, dated January 14, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included high blood pressure and dementia. Section N0415G (Diuretic) revealed that the resident did not receive a diuretic medication during the seven-day assessment period.

Physician's orders for Resident 85, dated July 16, 2024, included an order for the resident to receive 2.5-6. 25 milligram of bisoprolol hydrochlorothiazide (diuretic medication) one time a day for high blood pressure. A

review of Resident 85's MAR for January 2025 revealed that the resident received the diuretic medication

during the seven-day look-back period.

Interview with the Registered Nurse Assessment Coordinator on February 5, 2025, at 2:30 p.m. confirmed that Resident 85's quarterly MDS assessment was inaccurately coded regarding the diuretic medication.

A quarterly MDS assessment for Resident 88, dated January 7, 2025, revealed that the resident had severe cognitive impairment, was dependent on staff for care needs, and had diagnoses that included dementia. Section N0415F (Antibiotic) revealed that the resident did not receive an antibiotic during the look-back period and Section N0415K (anticonvulsant) revealed that the resident received an anticonvulsant medication during the look-back period.

Physician's orders for Resident 88, dated December 19, 2024, included an order for the resident to receive triple antibiotic ointment topically to his right fourth finger every day for a skin tear. Physician's orders, dated January 6, 2024, included for the resident to receive triple antibiotic ointment to sutures above his right eye twice day until January 13, 2025. Review of the MAR, dated January 2025, revealed that Resident 88 received an antibiotic during the seven-day look-back period but did not receive an anticonvulsant.

Interview with the Registered Nurse Assessment Coordinator on February 7, 2025, at 2:02 p.m. confirmed that Resident 88's January 7, 2025, MDS was inaccurately coded regarding antibiotic and anticonvulsant medication.

The RAI User's Manual, dated October 2024, indicated that the intent of Section A was to record the discharge status of the resident. Section A2105 was to be coded with the location of the resident's discharge.

A discharge tracking MDS assessment for Resident 131, dated January 11, 2025, indicated that the resident was discharged to home. A nursing note for Resident 131, dated January 12, 2025, at 12:14 a.m. indicated that the resident was admitted to the local hospital.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Interview with Director of Nursing on February 7, 2025, at 11:09 a.m. confirmed that Resident 131's discharge MDS assessment was coded inaccurately and that the resident was discharged to the local Level of Harm - Minimal harm or hospital. potential for actual harm 28 Pa. Code 211.5(f) Clinical Records. Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm 47819

Residents Affected - Few Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that comprehensive resident-centered care plans were developed and implemented for one of 43 residents reviewed (Resident 45).

Findings include:

The facility's policy regarding care plans, dated September 12, 2024, indicated that the facility will create a person-centered care plan including necessary and appropriate care, attending physician orders, services and accommodation of resident needs and preferences in order for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated November 25, 2024, revealed that the resident was cognitively intact, required assistance from staff for her daily care needs, required oxygen therapy, and had diagnoses that included atrial fibrillation (irregular heartbeat), high blood pressure, right femur fracture, asthma, and chronic obstructive pulmonary disease.

Physician's orders for Resident 45, dated November 18, 2024, included an order for the resident to receive oxygen at 2 liters per minute via nasal cannula.

There was no documented evidence that a care plan was developed to address Resident 45's individual care and treatment needs related to his use of oxygen.

Interview with the Director of Nursing on February 4, 2025, at 1:18 p.m. confirmed that there was no care plan developed for Resident 45's care and treatment needs related to his use of oxygen.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm 46994

Residents Affected - Some Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect specific care needs for three of 43 residents reviewed (Residents 8, 26, 42).

Findings include:

A facility policy for care plans, dated September 12, 2024, indicated that care plans will be reviewed and revised as necessary by the interdisciplinary team at least quarterly after each Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) or more often as changes occur.

An annual MDS assessment for Resident 8, dated December 21, 2024, indicated that the resident was cognitively impaired, required assistance with care needs, used oxygen, and had a diagnosis of hemiplegia and hemiparesis (paralysis or weakness to one side of the body due to brain injury). A respiratory care plan for Resident 8, dated December 19, 2024, indicated that the resident was to be provided oxygen as ordered.

A nursing note for Resident 8, dated January 25, 2025, at 3:54 p.m., revealed that the resident does not wear his oxygen as ordered and his oxygen saturation (blood oxygen level) was measuring greater than 90 percent on room air (without supplemental oxygen). The doctor was notified, and his oxygen was discontinued.

Interview with the Director of Nursing on February 7, 2025, confirmed that Resident 8's care plan was not revised to reflect that his oxygen was discontinued and it should have been.

An admission MDS assessment for Resident 26, dated January 15, 2025, indicated that the resident was cognitively intact, required assistance with care needs, and had diagnoses that included pneumonia and clostridium difficile infection (C-Diff-a contagious infection affecting the colon). A care plan for Resident 26, dated January 10, 2025, indicated that the resident was taking an antibiotic related to C-diff infection and pneumonia and was on contact precautions (used to prevent the spread of infection passed through direct contact with an infected person or their environment) for the C-diff infection.

Physician's orders for Resident 26, dated January 10, 2025, indicated that the resident was to be placed on contact precautions for 10 days through January 19, 2025.

Observations on February 3, 2025, at 9:53 a.m. revealed that the resident had signage on her door for contact precautions; however, as of February 5, 2025, there was no documented evidence in Resident 26's clinical record that she was ordered an antibiotic.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Interview with the Nursing Home Administrator on February 5, 2025, at 11:53 a.m. confirmed that Resident 26's care plan for the antibiotic related to the C-diff infection and PNA should have been revised to reflect Level of Harm - Minimal harm or that she was no longer on antibiotic therapy and confirmed that her care plan should have been revised to potential for actual harm reflect that the contact precaution for the C-diff were discontinued.

Residents Affected - Some A quarterly MDS assessment for Resident 42, dated December 26, 2024, indicated that the resident was cognitively intact, required assistance with personal care needs, and had diagnoses that included chronic respiratory failure.

Review of the care plan for Resident 42, dated September 10, 2024, indicated that the resident was receiving anticoagulant (blood thinner) therapy.

Review of Resident 42's clinical record, including his medication administration record, revealed no documented evidence that the resident was receiving an anticoagulant.

Interview with the Registered Nurse Assessment Coordinator on February 7, 2025, at 8:30 a.m. confirmed that Resident 42 was not receiving an anticoagulant and his care plan should have been revised to reflect that.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31760 potential for actual harm Based on review of Pennsylvania's Nursing Practice Act, facility policies, clinical records, and facility Residents Affected - Some investigation documents, as well as staff interviews, it was determined that the facility failed to correctly transcribe physician's orders for one of 43 residents reviewed (Resident 9), and failed to ensure that a licensed practical nurse followed professional standards regarding the administration of medications for one of 43 residents reviewed (Resident 81).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals.

A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 9, dated January 30, 2025, revealed that the resident was cognitively intact, required assistance from staff for personal care needs, and had diagnoses that included coronary artery disease.

A physician's order note for Resident 9, dated October 30, 2024, at 1:07 a.m. revealed that the resident was seen by the certified registered nurse practitioner (a registered nurse who has advanced training and education) on October 29, 2024, and new orders were received for the resident to receive 20 milligrams (mg) of escitalopram (antidepressant medication) daily for depression.

An incident note for Resident 9, dated November 5, 2024, at 12:15 p.m. revealed that during a pharmacy medication/chart audit, it was noted that the resident was ordered 10 mg of escitalopram daily and 20 mg of escitalopram daily for a combined dose of 30 mg of escitalopram daily from October 30, 2024, to November 5, 2024. A transcription error was identified that the 10 mg of escitalopram was not discontinued when the medication was increased to 20 mg.

A physician's progress note, dated December 16, 2024, at 10:58 a.m., revealed that orders were placed to decrease escitalopram from 20 mg to 10 mg daily after a review from a previous hospitalization .

An incident note for Resident 9, dated December 19, 2024, at 6:59 a.m., revealed that an order was received from the certified registered nurse practitioner on December 16, 2024, to decrease escitalopram from 20 mg daily to escitalopram 10 mg daily. Escitalopram 20 mg was discontinued. The new order for escitalopram 10 mg daily was not entered into the clinical record. After review of a medication audit, the order was corrected, and the physician approved starting the escitalopram 10 mg daily that day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Interview with the Director of Nursing on February 5, 2025, at 2:49 p.m. revealed that Resident 9 received 30 mg of escitalopram instead of the ordered dose of 20 mg of escitalopram from October 30, 2024, through Level of Harm - Minimal harm or November 5, 2024, and did not receive the ordered dose of 10 mg of escitalopram on December 17 and 18, potential for actual harm 2024. Incident investigations were completed revealing that transcription errors were made in both occurrences. Residents Affected - Some

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 (a)(3) indicated that the Licensed Practical Nurse (LPN) is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. An LPN shall follow the written, established policies and procedures of the facility that are consistent with the act.

The facility's policy regarding medication administration, dated September 12, 2024, revealed that medications must be administered in accordance with the orders, including any required time frame. The individual administering medications must check the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking identification band and checking photograph attached to the medical record, and if necessary, verify resident identification with other facility personnel. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dose, right time, and method (route) of administration before giving the medication.

An annual MDS assessment for Resident 81, dated December 6, 2024, revealed that the resident was sometimes understood, sometimes understands, and had a diagnosis which included dementia. A care plan for the resident, dated December 16, 2023, revealed that the resident has a communication deficit related to cognitive deficits (refer to impairments in a person's thinking abilities).

A nursing note for Resident 81, dated December 17, 2024, revealed that Licensed Practical Nurse 1 reported to this registered nurse that this resident received another resident's medications in error. Agency Licensed Practical Nurse 2 reported that she went to the beauty shop to pick up Resident 93 to return her to room [ROOM NUMBER]-A to administer her medications. The nurse aides realized that Resident 81 was not in her assigned room of 230-A. The nurse aides found Resident 81 in room [ROOM NUMBER]-A. The nurse aides then returned Resident 81 to her room. Resident 81 had a moderate-sized emesis of what appeared to be medications. Licensed Practical Nurse 1 confirmed that she had not administered any medications to this resident this morning. Agency Licensed Practical Nurse 2 stated that she thought this resident was Resident 93, who lives in room [ROOM NUMBER]-A, and attempted to administer Resident 93's medications to this resident. This resident would not accept medications per Agency Licensed Practical Nurse 2. Assessment of

the resident revealed that the resident was up in her wheelchair per orders. She was alert to self, no distress noted. She looks at you when you speak to her but does not respond, and this is the resident's baseline. Vital signs were stable. The physician and the resident's responsible party were notified.

A statement by Agency Licensed Practical Nurse 2, dated December 17, 2024, revealed that she took the medications to the beauty salon. She asked the hairdresser which resident was Resident 93. She pointed to Resident 81 and stated that was Resident 93. She then tried to administer the medication to Resident 81 thinking that she was Resident 93. Resident 81 spit the medications out and would not take them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 An Interdisciplinary Team (IDT) note for Resident 81, dated December 17, 2024, revealed that the incident was reviewed by the IDT. The licensed practical nurse involved was an agency licensed practical nurse. The Level of Harm - Minimal harm or agency licensed practical nurse's agency was contacted regarding the probable medication error. Agency potential for actual harm Licensed Practical Nurse 2 was placed on a do not return to the facility list due to not following the administering medication rights. Residents Affected - Some

Interview with the Director of Nursing on February 7, 2025, at 1:05 p.m. confirmed that Agency Licensed Practical Nurse 2 did not follow the facility's policy when administering medications to a resident.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 31760 potential for actual harm Based on review of facility policies and clinical record reviews, as well as staff interviews, it was determined Residents Affected - Some that the facility failed to provide care and treatment in accordance with professional standards of practice by failing to follow physician's orders for two of 43 residents reviewed (Residents 10, 57).

Findings include:

The facility's policy regarding medication administration, dated September 12, 2024, revealed that medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dose, right time, and method (route) of administration before giving the medication.

Physician's orders for Resident 10, dated December 22, 2024, included an order for the resident to receive one 10 milligram (mg) tablet of Midodrine (used to treat low blood pressure (hypotension) three times a day for hypotension, and staff was to hold the medication if the resident's systolic blood pressure (the top number of the blood pressure) was greater than 120 millimeters of mercury (mmHg) or if the diastolic blood pressure (the bottom number of the blood pressure) was greater than 80 mmHg.

Resident 10's Medication Administration Records (MARs) for December 2024, January and February 2025, revealed that staff administered the one 10 mg tablet of Midodrine on December 22, 2024, at 8:30 a.m. for a blood pressure of 130/75 mmHg; on December 23, 2024, at 8:30 a.m. for a blood pressure of 124/48; on December 24, 2024, at 12:30 p.m. for a blood pressure of 126/60 mmHg; on December 26, 2024, at 12:30 p. m. for a blood pressure of 122/76 mmHg; on December 27, 2024, at 8:30 a.m. for a blood pressure of 169/83 mmHg; and on December 31, 2024, at 8:30 a.m. for a blood pressure of 122/66 mmHg, and at 12:30 p.m. for

a blood pressure of 126/72 mmHg; on January 4, 2025, at 12:30 p.m. for a blood pressure of 122/82 mmHg;

on January 5, 2025, at 8:30 a.m. for a blood pressure of 146/78 mmHg; on January 8, 2025, at 12:30 p.m. for

a blood pressure of 138/74 mmHg, and at 5:30 p.m. for a blood pressure of 130/78 mmHg; on January 10, 2025, at 12:30 p.m. for a blood pressure of 138/62 mmHg, and at 5:30 p.m. for a blood pressure of 152/100 mmHg; on January 11, 2025, at 8:30 a.m. for a blood pressure of 134/52 mmHg; on January 14, 2025, at 5:30 p.m. for a blood pressure of 126/68 mmHg; on January 15, 2025, at 12:30 p.m. for a blood pressure of 126/56 mmHg; and on January 25, 2025, at 8:30 a.m. for a blood pressure of 134/88 mmHg; and on February 2, 2025, at 8:30 a.m. for a blood pressure of 124/82 mmHg.

Interview with the Director of Nursing on February 5, 2025, at 10:51 a.m. confirmed that Resident 10's one 10 mg tablet of Midodrine should not have been administered on the above dates.

Physician's orders for Resident 57, dated July 16, 2024, included an order for the resident to receive one 10 mg tablet of Midodrine three times a day for hypotension, and staff was to hold the medication if the resident systolic blood pressure was greater than 120 mmHg or if the diastolic blood pressure was greater than 80 mmHg.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Resident 57's MARs for December 2024, January and February 2025, revealed that staff administered the one 10 mg tablet of Midodrine on December 9, 2024, at 8:30 p.m. for a blood pressure of 106/88 mmHg; on Level of Harm - Minimal harm or December 11, 2024, at 8:30 a.m. for a blood pressure of 116/82 mmHg, and at 8:30 p.m. for a blood potential for actual harm pressure of 120/88 mmHg; on December 17, 2024, at 8:30 a.m. for a blood pressure of 128/66 mmHg, and at 12:30 p.m. for a blood pressure of 126/64 mmHg; on December 25, 2024, at 8:30 p.m. for a blood Residents Affected - Some pressure of 136/66 mmHg; and on December 27, 2024, at 8:30 a.m. for a blood pressure of 126/78 mmHg;

on January 6, 2025, at 8:30 p.m. for a blood pressure of 128/70 mmHg; on January 9, 2025, at 8:30 p.m. for

a blood pressure of 124/68 mmHg; on January 14, 2025, at 8:30 a.m. for a blood pressure of 110/84 mmHg;

on January 15, 2025, at 8:30 p.m. for a blood pressure of 122/72 mmHg; and on January 23, 2025, at 8:30 p. m. for a blood pressure of 122/73 mmHg; and on February 3, 2025, at 12:30 p.m. for a blood pressure of 118/82 mmHg, and at 8:30 p.m. for a blood pressure of 129/76 mmHg.

Interview with the Director of Nursing on February 4, 2025, at 1:18 p.m. confirmed that Resident 57's one 10 mg tablet of Midodrine should not have been administered on the above dates.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 46994

Residents Affected - Few Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent accidents or injury were in place for one of 43 residents reviewed (Resident 88).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 88, dated January 7, 2025, revealed that the resident was cognitively impaired, was dependent on staff for daily care needs, and had diagnoses that included dementia.

Review of Resident 88's care plan, dated October 4, 2024, indicated that the resident was at risk for falling.

An intervention, dated October 22, 2024, indicated that the resident was to wear hipsters when out of bed.

Review of a nurse's note for Resident 88, dated November 9, 2024, at 9:34 p.m., revealed that the resident was observed lying on the floor in the solarium on B hall and he was not wearing hipsters.

Review of a nurse's note for Resident 88, dated January 31, 2025, at 4:12 p.m., revealed that the resident was observed lying on his left side on the floor in the 1B solarium, and hipsters were not on the resident.

Interview with the Director of Nursing on February 5, 2024, at 2:35 p.m. revealed that the resident was not wearing hipsters at the time of his fall on November 9, 2024, and January 31, 2025, because the task was not put on the nurse aide task list correctly so that the nurse aides were aware the resident should wear them. Interview with the Director of Nursing revealed that the nurse's note for Resident 88 did confirm that

the resident was not wearing hipsters at the time of his fall as care planned.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Level of Harm - Minimal harm or 31760 potential for actual harm Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility Residents Affected - Some failed to flush a PICC line (a tube placed in a vein that can be used to deliver fluids and/or medications) and

a peripheral intravenous catheter (a small, thin tube inserted into a vein in the arm, hand or foot to administer medications and/or fluids) as ordered by the physician for two of 43 residents reviewed (Residents 8, 117), failed to administer intravenous fluids as ordered by the physician for one of 43 residents reviewed (Resident 8), and failed to change PICC line dressing as ordered by the physician for one of 43 residents reviewed (Resident 122).

Findings include:

The facility's policy regarding PICC line dressing changes, dated September 12, 2024, indicated that the PICC's will be flushed every shift and after each use with five to 10 cubic centimeters (cc) of normal sterile saline (NSS - a mixture of water and salt with a salt concentration of 0.9 percent) and five cc of Heparin (used to prevent and treat blood clots) if the physician's orders indicate.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated December 21, 2024, indicated that the resident was cognitively impaired, required assistance with care needs, used oxygen, and had a diagnosis of hemiplegia and hemiparesis (paralysis or weakness to one side of the body due to brain injury).

Physician's orders for Resident 8, dated December 15, 2024, included an order for staff to administer 800 milliliters (ml) of sodium chloride solution 0.9 percent intravenously (a way of giving a drug or other substance through a needle or tube inserted into a vein) for low sodium every shift for a total of two liters (2, 000 ml) through December 16, 2024.

Physician's orders for Resident 8, dated December 16, 2024, included an order for staff to administer sodium chloride solution 0.9 percent intravenously at a rate of 70 ml per hour one time only for hydration for one day for a total of one liter.

Physician's orders for Resident 8, dated December 18, 2024, included an order for staff to administer sodium chloride solution 0.9 percent intravenously at a rate of 75 ml per hour every shift for poor intake for a total of one liter.

Review of Resident 8's Medication Administration Record (MAR), dated December 2024, revealed that there was no documented evidence that the resident received the ordered amount of sodium chloride solution as per physician orders.

Interview with Director of Nursing on February 7, 2025, at 1:29 p.m. confirmed that there was no documented evidence that Resident 8 received the ordered amount of sodium chloride solution as per physician orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Physician's orders for Resident 8, December 15, 2024, included an order for staff to flush the resident's intravenous line to his left wrist with 10 cc of NSS every shift prior to intravenous medication/fluid Level of Harm - Minimal harm or administration and 10 cc of NSS every shift after intravenous medication/fluid administration. potential for actual harm Physician's orders for Resident 8, dated December 16, 2024, included an order for the resident to receive Residents Affected - Some one gram (gm) of ceftriaxone sodium solution (an antibiotic) intravenously one time a day pending urine culture through December 21, 2024.

Review of Resident 8's MARs dated December 2024, revealed that there was no documented evidence that staff flushed the resident's intravenous line with 10 cc of NSS prior to and after administration of ceftriaxone

on the day shift on December 16, 2024; on the day shift on December 20, 2024; on the evening shift on December 15 and 19, 2024; and on the night shift for December 19, 2024.

Interview with the Director of Nursing on February 7, 2025, at 1:14 p.m. confirmed that there was no documented evidence that the staff flushed Resident 8's intravenous line on the above mentioned dates and shifts.

Physician's orders for Resident 117, dated September 16, 2024, included an order for staff to flush the resident's PICC with 10 cc of NSS every shift for six weeks.

Review of Resident 117's MARs, dated September 2024, revealed that there was no documented evidence that staff flushed the resident's PICC with the 10 cc of NSS during the evening shift on September 20 through 23, 2024, and during the night shift on September 22, 2024.

Physician's orders for Resident 117, dated September 23, 2024, included an order for staff to flush the resident's PICC with 200 units of Heparin every night shift for six weeks.

Review of Resident 117's MARs, dated September and October 2024, revealed that there was no documented evidence that staff flushed the resident's PICC with the 200 units of Heparin during the night shift on September 27, and 28, 2024, and on October 4 through 6, and 25, 2024.

Physician's orders for Resident 117, dated September 23, 2024, included an order for staff to flush the resident's PICC with 10 cc of NSS every shift for six weeks.

Review of Resident 117's MARs, dated September and October 2024, revealed that there was no documented evidence that staff flushed the resident's PICC with the 10 cc of NSS during the day shift on September 26 and 30, 2024, and on October 4, 2024; during the evening shift on September 24, 25, 28, and 30, 2024, and on October 1, 4, 5, 10, 11, 14, 15, 23, and 25, 2024; and during the night shift on September 27 and 28, 2024, and on October 4, 5, 6, and 25, 2024.

Physician's orders for Resident 117, dated September 16, 2024, included an order for the resident to receive one gram (gm) of Vancomycin (an antibiotic) intravenously every 12 hours.

There was no documented evidence that Resident 117's physician was contacted for orders to flush the resident's midline with a saline solution prior to and/or after medication administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Review of Resident 117's MARs, dated September 2024, revealed that staff administered the one gm of Vancomycin intravenously on September 16, 2024, at 6:00 p.m.; on September 17, 18, and 19, 2024 at 6:00 Level of Harm - Minimal harm or a.m. and 6:00 p.m.; and on September 20, 2024, at 6:00 a.m. However, there was no documented evidence potential for actual harm that Resident 117's midline was flushed with a saline solution before and after the administration of the Vancomycin. Residents Affected - Some Physician's orders for Resident 117, dated September 23, 2024, included an order for the resident to receive two gms of Ceftriaxone (an antibiotic) intravenously (a way of giving a drug or other substance through a needle or tube inserted into a vein) every 24 hours.

There was no documented evidence that Resident 117's physician was contacted for orders to flush the resident's midline with a saline solution prior to and/or after medication administration.

Review of Resident 117's MARs, dated September, October, and November 2024, revealed that staff administered the two gms of Ceftriaxone intravenously daily on September 24 through 27, and 30, 2024; on October 1 through 4, 8 through 25, 27 through 31, 2024; and on November 1 through 4, 2024. However, there was no documented evidence that Resident 117's PICC was flushed with a saline solution before and

after the administration of the Ceftriaxone.

Interview with the Director of Nursing on February 7, 2025, at 12:06 p.m. confirmed that there was no documented evidence that Resident 117's PICC was flushed with the 10 cc of NSS every shift, flushed with 200 units of Heparin every night shift, and flushed with 10 cc of NSS every shift on the above dates. She indicated that the resident's PICC was to be flushed with a saline solution before and after the administration of the antibiotics and confirmed that there was no documented evidence that the resident's physician was contacted for orders to flush the resident's midline with a saline solution prior to and/or after medication administration, and confirmed that there was no documented evidence that the resident's PICC was flushed with a saline solution prior to and/or after the Vancomycin and Ceftriaxone administration on the above dates

The facility's policy regarding PICC line dressing changes, dated September 12, 2024, revealed that dressings were changed at 24 hours with new insertion then every seven days and as needed if loose, wet, or soiled.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of the resident's abilities and care needs) for Resident 122, dated January 22, 2025, indicated that the resident was cognitively intact, required assistance for daily care needs, received IV medications, and had medical diagnosis that include high blood pressure and sepsis.

Observation on February 5, 2025, at 11:00 a.m. revealed that Resident 122 was sitting in his chair PICC line

in right arm and was dated January 28, 2025.

Physician's orders, dated January 21, 2025, included orders for resident's PICC line to be changed every seven days on nightshift.

Resident 122's Medication Administration Record for April 2024 revealed that the residents PICC line was due to be changed February 4, 2025, and that the treatment was not signed off as completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Interview with the Registered Nurse 3 on February 5, 2025, at 11:06 a.m. confirmed that Resident 122's PICC line was dated January 28, 2024, and that it should have been changed last night per physician orders Level of Harm - Minimal harm or and it was not. potential for actual harm

Interview with the Director of Nursing on February 5, 2025, at 2:24 p.m. confirmed that Resident 122's PICC Residents Affected - Some line should have been changed per physician order and it was not.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 46994 potential for actual harm Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to Residents Affected - Few ensure that nurse aide performance evaluations were completed annually based on hire dates for one of three nurse aides reviewed (Nurse Aide 4).

Findings include:

A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 4 was due by April 8, 2024. However, there was no documented evidence that an annual performance evaluation was completed between March 15, 2023, and January 15, 2025, as required for this nurse aide.

Interview with the Nursing Home Administrator on February 7, 2025, at 11:09 a.m. confirmed that an annual performance evaluation was not completed as required for Nurse Aide 4.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 31760

Residents Affected - Few Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of 43 residents reviewed (Resident 80).

Findings include:

Physician's orders for Resident 80, dated July 16, 2024, included an order for the resident to receive one 50 milligram (mg) tablet of Tramadol (a narcotic medication to treat moderate to severe pain) every six hours as needed for moderate to severe pain.

Resident 80's controlled drug logs for December 2024 and January 2025 revealed that staff signed out doses of Tramadol for administration to the resident on December 9, 2024, at 9:00 a.m.; December 20, 2024, at 9:00 a.m.; December 23, 2024, at 9:00 a.m.; December 29, 2024, at 9:00 a.m.; January 11, 2025, at 8:30 p.m.; January 12, 2025, at 9:00 a.m.; and on January 16, 2025, at 9:40 a.m. However, the resident's clinical record, including the Medication Administration Records (MARs) and the nursing notes, revealed no documented evidence that the Tramadol was administered to the resident on these dates and times.

Interview with the Director of Nursing on February 7, 2025, at 11:09 a.m. confirmed that there was no documented evidence that the Tramadol was administered to Resident 80 on these dates and times.

28 Pa. Code 211.9(j)(3) Pharmacy Services.

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

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31760 potential for actual harm Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the Residents Affected - Some facility failed to ensure that physician's orders for medications were followed, resulting in significant medication errors for one of 43 residents reviewed (Resident 3), and failed to ensure that residents were free from significant medication errors for one of 43 residents reviewed (Resident 81).

Findings include:

The facility's policy regarding medication administration, dated September 12, 2024, revealed that medications must be administered in accordance with the orders, including any required time frame. The individual administering medications must check the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: checking identification band, checking photograph attached to the medical record, and if necessary, verify resident identification with other facility personnel.

The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dose, right time, and method (route) of administration before giving the medication.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 29, 2024, indicated that the resident had moderate cognitive impairment, required assistance from staff for personal care needs, and had diagnosis that included a displaced trimalleolar fracture of the left lower leg (fracture in the ankle joint on the left leg).

A physician's order note for Resident 3, dated November 25, 2024, at 12:44 p.m., revealed orders to stop Xarelto (an anticoagulant taken by mouth) and start Lovenox (an anticoagulant given by injection) twice a day, and were confirmed and verified.

Review of the Medication Administration Record (MAR) for Resident 3, dated November 2024, revealed that 20 milligrams (mg) of Xarelto was administered at 9:30 a.m. on November 26, 27, 28, and 29, 2024.

Interview with the Director of Nursing on February 7, 2024, at 11:09 a.m. revealed that Resident 3 received Xarelto for four days after it was discontinued and should not have.

An annual MDS assessment for Resident 81, dated December 6, 2024, revealed that the resident was sometimes understood, sometimes understands, and had a diagnosis which included dementia. A care plan for the resident, dated December 16, 2023, revealed that the resident has a communication deficit related to cognitive deficits (refer to impairments in a person's thinking abilities).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 A nursing note for Resident 81, dated December 17, 2024, revealed that Licensed Practical Nurse 1 reported to the registered nurse that the resident received another resident's medications in error. Agency Licensed Level of Harm - Minimal harm or Practical Nurse 2 reported that she went to the beauty shop to pick up Resident 93 to return to room [ROOM potential for actual harm NUMBER]-A to administer her medications. The nurse aides realized that Resident 81 was not in her assigned room of 230-A. The nurse aides found Resident 81 in room [ROOM NUMBER]-A. The nurse aides Residents Affected - Some then returned Resident 81 to her room. Resident 81 had a moderate-sized emesis of what appeared to be medications. It was confirmed with Licensed Practical Nurse 1 that she had not administered any medications to the resident this a.m. Agency Licensed Practical Nurse 2 stated that she thought this resident was Resident 93, who lives in room [ROOM NUMBER]-A, and attempted to administer Resident 93's medications to this resident. The resident would not accept medications per Agency Licensed Practical Nurse 2. Assessment of the resident revealed that the resident was up in her wheelchair per orders. She was alert to self, no distress noted. She does look at you when you speak to her but does not respond, and this is

the resident's baseline. Vital signs were stable. The physician and the resident's responsible party were notified.

A statement by Agency Licensed Practical Nurse 2, dated December 17, 2024, revealed that she took the medications to the beauty salon. She asked the hairdresser which resident was Resident 93. She pointed to Resident 81 and stated that was Resident 93. She then tried to administer the medication to Resident 81 thinking that she was Resident 93. Resident 81 spit the medications out and would not take them.

An Interdisciplinary Team (IDT) note for Resident 81, dated December 17, 2024, revealed that the incident was reviewed by the IDT. The licensed practical nurse involved was an agency licensed practical nurse. The agency licensed practical nurse's agency was contacted regarding the probable medication error. Agency Licensed Practical Nurse 2 was placed on a do not return to the facility list due to not following the administering medication rights.

Interview with the Director of Nursing on February 7, 2025, at 1:05 p.m. confirmed that Agency Licensed Practical Nurse 2 did not follow the facility's policy when administering medications to a resident and administered another resident's medications to Resident 81.

28 Pa Code 211.9(a)(1) Pharmacy Services.

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

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 31760 Residents Affected - Few Based on a review of facility policies, manufacturer's instructions, and clinical records, as well as

observations and staff interviews, it was determined that the facility failed to securely store medication for one of 43 residents reviewed (Resident 57), and failed to label multi-dose containers of medications with the date they were opened in one of three medication carts observed (Third floor medication cart).

Findings include:

The facility's policy regarding medication administration, dated September 12, 2024, revealed that residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of the resident's abilities and care needs) for Resident 57, dated December 17, 2024, revealed that the resident was understood and could understand others. A care plan for the resident, dated April 9, 2024, revealed that the resident was on diuretic therapy (medications that increase urine output by promoting the excretion of water and electrolytes through the kidneys) related to ascites (a condition where excess fluid accumulates in the abdominal cavity between the liver, stomach, intestines, and other organs), and staff was to administer his medications as ordered.

Physician's orders for Resident 57, dated October 5, 2024, included an order for the resident to receive one 100 milligram (mg) tablet of Spironolactone (a type of medicine called a diuretic) one time a day.

The resident's Medication Administration Record (MAR), dated February 2025, revealed that the Spironolactone was administered on the morning of February 3, 2025.

Observations on February 3, 2025, at 10:04 a.m. revealed that Resident 57 was lying in bed on top of the covers, and there was a white, round tablet lying in the resident's bed on top of the covers.

Interview with Licensed Practical Nurse 5 on February 3, 2025, at 10:05 a.m. confirmed that there was a white, round tablet lying in Resident 57's bed on top of the covers. Licensed Practical Nurse 5 then picked up

the white, round tablet in a tissue and took it to Licensed Practical Nurse 6, who was assigned to administer medications to the residents on that hall. She confirmed that it was the resident's 100 mg tablet of Spironolactone.

Interview with the Director of Nursing on February 4, 2025, at 2:40 p.m. confirmed that Resident 57 was not able to self-administer his own medications, and that the Spironolactone should not have been on his bed.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Manufacturer's directions on the container for use of Trelegy Ellipta (used to treat chronic obstructive pulmonary disease, a condition that causes inflammation and narrowing of the airways) inhaler revealed that Level of Harm - Minimal harm or the inhaler was to be discarded six weeks after being removed from the foil pouch. potential for actual harm

The facility's policy regarding medication administration, dated September 12, 2024, revealed that the Residents Affected - Few expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container.

The facility's policy regarding medication storage, dated September 12, 2024, revealed that when the original seal of the manufacture's container or vial is initially broken, the container or vial will be dated.

Physician's orders for Resident 76, dated November 13, 2024, included an order for the resident to receive one 200-62.5-25 microgram (mcg) puff from the Trelegy Ellipta inhaler every day shift.

Observations of the Third-floor medication cart on February 7, 2025, at 10:32 a.m. revealed that the 200-62. 5-25 mcg Trelegy Ellipta inhaler for Resident 76 was opened and not dated with the date that it was opened.

Interview with Licensed Practical Nurse 6 at the time of observation confirmed that the inhaler for Resident 76 was opened and not dated with the date it was opened, and it should have been dated.

28 Pa. Code 211.9(a)(1)(h) Pharmacy Services.

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

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 31760

Residents Affected - Some Based on a review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for three of 43 residents reviewed (Residents 45, 117, 122).

Findings include:

A significant Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated November 25, 2024, revealed that the resident was cognitively intact, required assistance from staff for her daily care needs, required oxygen therapy, and had diagnoses that included atrial fibrillation (irregular heartbeat), high blood pressure, right femur fracture, asthma, and chronic obstructive pulmonary disease.

Review of nurse aide documentation of care for Resident 45, dated December 2024 and January 2025, revealed that the resident was to be showered each Monday and Friday evening. Documentation for Resident 45 for December 2, 9, 13, 16, 20, 23, 27,30, 2024, and January 3, 6, 10, 13, 17, 20, 24 and 31, 2025, indicated not applicable for showers/bath. There was no documentation on these days that the resident was offered a shower or bed bath or that she refused a shower or bed bath.

Interview with the Director of Nursing on February 7, 2025, at 12:08 p.m. revealed that Resident 45's showers were scheduled for the daytime and inaccurately entered the charting system. She stated the resident was a day shift shower and that is why night shift was documentation not applicable. She confirmed there was no documentation in the resident's clinical record that she received a shower on those dates listed above.

Physician's orders for Resident 117, dated September 23, 2024, included an order for the resident to receive two gms of Ceftriaxone (an antibiotic) intravenously (a way of giving a drug or other substance through a needle or tube inserted into a vein) every 24 hours.

Review of Resident 117's Medication Administration Records (MARs), dated September and October 2024, revealed that there was no documented evidence that staff signed as administering the two gms of Ceftriaxone intravenously daily on September 28, and 29, 2024, and October 5 through 7, and 26, 2024.

Interview with the Director of Nursing on February 7, 2025, at 12:06 p.m. confirmed that the Ceftriaxone was not signed off as being administered on Resident 117's MAR. She stated that she verified it with the pharmacy and that there were no missing doses, so the nurses must not have signed it as being administered.

An admission MDS assessment for Resident 122, dated January 22, 2025, indicated that the resident was cognitively intact, required assistance for daily care needs, received intravenous medications, and had medical diagnosis that include high blood pressure and sepsis (a life-threatening condition that occurs when

the body's immune system overreacts to an infection).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Physician's orders, dated January 18, 2025, for Resident 122 to receive 1500 milligrams (mg) of Vancomycin (antibiotic) IV every 12 hours for bacteremia (a condition where bacteria are present in the bloodstream). A Level of Harm - Minimal harm or review of the resident's January 2025 MAR revealed that the medication was not signed off as administered potential for actual harm on January 20 and 26, 2025.

Residents Affected - Some An interview with the Director of Nursing on February 5, 2025, at 2:24 p.m. confirmed that the medication was not signed off as administered on the MAR. She stated that she verified with the pharmacy that there were no missing doses that the nurses must not have signed them off as administered.

28 Pa Code 211.5(f) Clinical Records.

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

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm 31760

Residents Affected - Some Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for three of 43 hospice residents reviewed (Residents 18, 57, 93).

Findings include:

The facility's policy regarding Hospice services (a type of end-of-life care that includes physical, emotional, and spiritual support for people with terminal illnesses), dated September 12, 2024, revealed that Hospice will provide the skilled nursing facility within 48 to 72 hours of admission the following: A copy of the physician's certification of terminal illness (a form signed by the resident's hospice physician and specific to each patient); a copy of the Hospice agreement signed by the resident/resident's legal representative; and a copy of the Hospice coordinated plan of care. The Hospice documents will be a part of the resident's medical

record and filed either on the chart or in a separate folder, which remains with the chart. Coordinated plan of care is filed with the resident's care plan. Copies of all hospice visits documentation will be filed in the chart.

The facility's designated staff member is responsible for obtaining the following information from the Hospice:

The most recent Hospice plan of care specific to each resident; Hospice election form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to

the terminal illness); physician certification and recertification of the terminal illness specific to each resident; names and contact information for hospice personnel involved in hospice care of each resident; instructions

on how to access the hospice 24-hour on-call system; hospice medication information specific to each resident; and hospice physician and attending physician (if any) orders specific to each resident.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of the resident's abilities and care needs) for Resident 18, dated December 10, 2024, revealed that the resident is cognitively impaired, required assistance from staff for daily care needs, and had medical diagnoses that include dementia, high blood pressure, and history of a stroke.

Physician's orders for Resident 18, dated July 15, 2024, revealed that the resident was to receive hospice services from the facility's contracted hospice provider. As of February 5, 2025, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained

the physician certification form and nursing notes from the hospice provider.

Interview with the Director of Nursing on February 5, 2025, at 12:25 p.m. revealed that there was no evidence that the physician certification and nursing notes were on Resident 18's hospice chart.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 A quarterly MDS assessment for Resident 57, dated December 17, 2024, revealed that the resident was understood, could understand others, had diagnoses that included alcoholic cirrhosis (a chronic liver disease Level of Harm - Minimal harm or caused by long-term, excessive alcohol consumption) of the liver with ascites (a condition where excess fluid potential for actual harm accumulates in the abdominal cavity) and chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause airflow obstruction and breathing problems), and received hospice services. A care plan Residents Affected - Some for the resident, dated September 11, 2024, revealed that the resident was receiving hospice services due to

a terminal condition. Staff was to collaborate with the hospice provider to ensure services were coordinated to meet the resident's and family's needs.

Physician's orders for Resident 57, dated September 11, 2024, included an order for the resident to be admitted to hospice.

Review of Resident 57's clinical record, as well as the resident's hospice clinical record revealed that there was no current hospice plan of care and/or hospice visit notes after the last hospice visit that was completed

on December 11, 2024.

Interview with the Director of Nursing on February 5, 2025, at 12:27 p.m. confirmed that there was no documented evidence that Resident 57's clinical record, as well as the resident's hospice clinical record contained a current hospice plan of care and/or hospice visit notes after the last hospice visit that was completed on December 11, 2024.

A significant change MDS assessment for Resident 93, dated January 24, 2025, revealed that the resident was cognitively impaired, required assistance from staff for daily care tasks, had an unstageable pressure ulcer (full-thickness pressure injury involving tissue damage and death) and a venous ulcer (ulcers caused by problems with blood flow in the leg veins), had diagnoses that included peripheral vascular disease (a disease causing poor blood circulation to lower limbs) and diabetes, and received hospice services. A care plan for the resident, dated January 20, 2025, revealed that the resident was receiving hospice services due to a terminal condition. Physician's orders for Resident 57, dated September 11, 2024, included an order for

the resident to be admitted to hospice.

Physician's orders for Resident 93, dated January 19, 2025, included an order for the resident to be admitted to hospice services. As of February 5, 2025, there was no documented evidence in the resident's clinical

record that the facility obtained any of the required hospice records from the hospice provider.

Interview with the Director of Nursing on February 5, 2025, at 12:29 p.m. confirmed that the facility had no hospice records in a hospice binder or uploaded into the electronic medical record for Resident 93 since the resident was admitted to hospice on January 19, 2025.

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

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 31760

Residents Affected - Some 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 maintain compliance with nursing home regulations 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 State Survey and Certification (Department of Health) survey ending March 7, 2024, 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 7, 2025, identified repeated deficiencies related to a failure to complete accurate Minimum Data Set (MDS) assessments (mandated assessment of a resident's abilities and care needs); failure to update residents' care plans; failure to provide professional nursing services; failure to provide quality care; failure to provide safety/prevent accidents; failure to properly store and label medications; and failure to ensure proper infection control practices were followed.

The facility's plan of correction for a deficiency regarding a failure to ensure that MDS assessments were accurate upon submission, cited during the survey ending March 7, 2024, revealed that the facility developed

a plan 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

F-F641, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to accurate MDS assessments.

The facility's plan of correction for a deficiency regarding a failure to update residents' care plans, cited

during the survey ending March 7, 2024, revealed that the facility developed a plan 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

F-F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating residents' care plans.

The facility's plan of correction for a deficiency regarding professional nursing services, cited during the survey ending March 7, 2024, 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

F-F658, revealed that

the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding professional nursing services.

The facility's plan of correction for a deficiency regarding quality care, cited during the survey ending March 7, 2024, 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

F-F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality care.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 The facility's plans of correction for deficiencies regarding providing a safe environment free of accident hazards, cited during the survey ending March 7, 2024, revealed that the facility developed plans of Level of Harm - Minimal harm or correction that included completing audits and reporting the results of the audits to the QAPI committee for potential for actual harm review. The results of the current survey, cited under

F-F689, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to safety and accident-free environments. Residents Affected - Some

The facility's plan of correction for a deficiency regarding storing/labeling medications properly, cited during

the survey ending March 7, 2024, revealed that the facility developed a plan 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

F-F761, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to storing/labeling medications properly.

The facility's plans of correction for deficiencies regarding infection control practices, cited during the survey ending March 7, 2024, revealed that the facility would complete audits, and the results would be reviewed as part of quality assurance. The results of the current survey, cited under

F-F880.

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

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 31760 potential for actual harm Based on review of established infection control guidelines, facility policy, and residents' clinical records, as Residents Affected - Some well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for four of 43 residents reviewed (Residents 10, 27, 65, 93).

Findings include:

CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP's) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP's

during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

The facility's policy regarding EBP's, dated September 12, 2024, indicated that EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization or infection status. Wounds are those that are chronic or longer healing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot wounds, unhealed surgical wounds, and venous stasis ulcers. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of the resident's abilities and care needs) for Resident 10, dated December 27, 2024, revealed that the resident was usually understood, could usually understand others, had a diagnosis which included end-stage renal disease (ESRD - permanent kidney failure that requires a regular course of dialysis or a kidney transplant), and dementia, and received hemodialysis (a treatment that removes waste and extra fluid from the blood when the kidneys are not working properly).

A nursing note for Resident 10, dated December 21, 2024, revealed that the resident was admitted to the facility from the hospital and that the resident receives hemodialysis on Monday, Wednesday, and Friday, and had a left chest wall tunneled catheter (a long-term vascular access device used for hemodialysis).

Observations of Resident 10's room on February 3, 2025, at 10:31 a.m.; on February 4, 2025, at 11:14 a.m.; and on February 5, 2025, at 11:56 a.m. revealed that the door to the resident's room was closed, and there was no infection control sign posted at the entrance to the resident's room to indicate that the resident required EBPs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Interview with Registered Nurse/Infection Control Preventionist on February 4, 2025, at 12:37 p.m. confirmed that Resident 10 should be on EBPs due to having the left chest wall tunneled catheter. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on February 4, 2025, at 2:40 p.m. confirmed that Resident 10 should be on EBPs. Residents Affected - Some

An annual MDS assessment for Resident 27, dated January 21, 2025, revealed that the resident had severe cognitive impairment, was dependent on staff for care needs, had a feeding tube (a medical device that delivers nutrition, fluids, and sometimes medicine directly into the stomach or small intestine), and had a diagnosis that include stroke.

Physician's orders for Resident 27, dated July 16, 2024, revealed that the resident was to have placement of her feeding tube verified before every feeding and medication administration per facility policy.

Observations of Resident 27's room on February 2, 2025, at 10:36 a.m. and on February 4, 2025, at 12:30 p. m. revealed that there was no infection control sign posted at the entrance to the resident's room to indicate that the resident required EBPs.

Interview with Registered Nurse 8 on February 4, 2025, at 12:35 p.m. confirmed that Resident 27 had a feeding tube in place and did not have any EBP's in place.

Interview with Nursing Home Administrator on February 4, 2025, at 3:05 p.m. confirmed that Resident 27 should have been on EBPs because she had a feeding tube in place.

A quarterly MDS assessment for Resident 65, dated December 17, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included an open wound to her left lower leg. A care plan for the resident, dated January 2, 2025, revealed that the resident has the potential for altered skin integrity related to non-healing wounds to her left lower extremity. A care plan, dated October 14, 2024, and revised on February 5, 2025, revealed that the resident was on EBPs related to chronic wounds, ad that staff was to educate the resident and her family on EBPs as needed, and that PPE was available when providing care with high contact activities.

Physician's orders for Resident 65, dated January 5, 2025, included an order for staff to moisten the dressing to resident's left lateral (to the side of, or away from, the middle of the body) calf hematoma (a localized collection of blood outside of blood vessels that forms as a result of trauma or injury) with normal sterile saline (NSS - a mixture of water and salt with a salt concentration of 0.9 percent) prior to removal. Then cleanse the wound with 0.25 percent acetic acid (used for the treatment of chronic wound), then apply Vaseline moisturizer to the peri skin (the skin around a wound), then apply collagen powder (to treat the loss of skin hydration) mixed with bacitracin (topical antibiotic ointment) to the base of the wound, then secure with an ABD pad (a specialized medical dressing designed to manage and protect moderate to heavily draining wounds), rolled gauze, and then apply an ACE wrap from her toes to beneath her knee every day.

Observations of Resident 65's room on February 3, 2025, at 12:32 p.m. and on February 4, 2025, at 11:37 a. m. revealed that the resident was in her room, and there was no infection control sign posted at the entrance to the resident's room to indicate that the resident required EBPs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 36 395830 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395830 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Interview with Registered Nurse/Infection Control Preventionist on February 4, 2025, at 12:37 p.m. revealed that for residents that have wounds, they do not place the resident on EBP, unless there is an infection in the Level of Harm - Minimal harm or wound or there is some other type of problem. She indicated that if the wound could be covered, they would potential for actual harm not be on EBP. She indicated that a resident should be on EBP if they have any type of medical device inserted. Residents Affected - Some

Interview with the Director of Nursing on February 4, 2025, at 2:40 p.m. confirmed that Resident 65 should be on EBPs.

A significant change MDS assessment for Resident 93, dated October 24, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care tasks, had an unstageable pressure ulcer (full-thickness pressure injury involving tissue damage and death) and a venous ulcer (ulcers caused by problems with blood flow in the leg veins), and had diagnoses that included peripheral vascular disease (a disease causing poor blood circulation to lower limbs) and diabetes. An active care plan for Resident 93, dated September 20, 2024, revealed that she had a pressure ulcer to her left outer heel.

Physician's orders for Resident 93, dated January 27, 2025, included an order for the staff to cleanse the pressure wound to her left lateral heel with wound cleanser, apply skin prep to peri wound, apply medical grade honey to wound base, cover with 2x2 gauze and bordered foam every day shift every other day.

Observations of Resident 93's room on February 4, 2025, at 9:18 a.m. revealed that the resident was in her room, and there was no infection control signage posted at the entrance to the resident's room and no PPE to indicate that the resident required EBPs.

Interview with Registered Nurse/Infection Control Preventionist on February 4, 2025, at 11:18 a.m. revealed that EBP would be implemented for a resident that has an MDRO in a wound but not necessarily for chronic wounds in general.

Interview with the Nursing Home Administrator on February 4, 2025, at 3:05 p.m. confirmed that Resident 93 should have been on EBP related to her wounds and she was not.

Observations of Resident 93's wound care on February 5, 2025, at 9:15 a.m. revealed that Licensed Practical Nurse 7 did not apply the appropriate PPE prior to starting wound care to the resident's left heel.

Interview with Licensed Practical Nurse 7, after completing Resident 93's wound care at 9:26 a.m., revealed that she saw the EBP signage on the door frame and the PPE on the door but was not sure why the resident was on EBP. She confirmed she did not apply a gown prior to wound care because she did not think she had to unless dressing a wound with an MDRO.

Interview with the Nursing Home Administrator on February 5, 2025, at 11:53 a.m. confirmed that the Licensed Practical Nurse should have donned a gown to perform wound care.

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

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

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 36 395830