Meadowcrest Rehabilitation & Healthcare Center

During an interview on 3/6/26, at approximately 12:00 p.m., the Nursing Home Administrator confirmed the facility failed to post contact information for the Medicaid Fraud on two of two nursing units. 28 Pa.

Code: S201.29(i) Resident rights.

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

During an interview on 3/6/26, at approximately 12:00 p.m. the Nursing Home Administrator confirmed the facility failed to post the most recent Federal or State survey results for one of one survey books. 28 Pa.

Code 201.14 Responsibility of licensee

During an interview on 3/6/26, at approximately 12:00 p.m., the Nursing Home Administrator confirmed the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid on two of two nursing units. 28 Pa.

Code: S201.29(i) Resident rights.

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

Review of Resident R7's clinical record failed to reveal that the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication.

Review of the clinical record indicated Resident R41 was admitted on [DATE].

Review of Resident R41's MDS dated [DATE], indicated diagnoses of dementia and chronic pain.

Review of Resident R41's physician order dated 11/25/25, indicated to administer haloperidol 0.5mg every twelve hours PRN for agitation.

Review of Resident R41's clinical record failed to reveal that the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication.

During an interview on 3/6/26, at approximately 10:30 a.m. the Nursing Home Administrator confirmed that the facility failed to ensure that the residents medication regime was free from unnecessary psychotropic medication for four of seven residents. 28 Pa.

Code 211.2(d)(3) Medical Director 28 Pa.

Code 211.10(a) Resident care policies.

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

Review of the facility policy Accidents and Incidents- Investigating and Reporting dared 1/8/26, with a previous review date of 1/14/25, indicated that all accidents and incidents involving residents, employees, etc., occurring on the premises shall be investigated and reported to the Administrator.

The Nurse Supervisor shall promptly initiate and document the investigation of the accident or incident.

Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE].

Review Resident R8's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 2/14/26, indicated diagnoses of dementia, psychotic and mood disturbances, anxiety, obesity and dysphagia.

Review of Resident R8's MDS dated [DATE], indicated substantial/maximal assistance for bed mobility.

During a clinical record review, a progress note dated 1/7/26, indicated Resident R8 had a fall out of bed when being provided care which resulted in a laceration above her eyebrow which required treatment.

Review of Resident R8's plan of care for Falls indicated resident is at risk for falls and to provide assistance as required.

Bilateral fall mats to be in place.

During an observation on 3/4/26, at 3:00 p.m., fall mat on right side of bed close to wall and leaning onto wall, no mat on left side of bed and Resident R8 had legs bent leaning towards left side of bed.

During an observation on 3/5/26, at 9:00 a.m., fall mat on right side of bed unmoved from previous day and no mat on left side of bed.

During an interview on 3/4/25, at 3:00 p.m., Registered Nurse Employee E6 and Nurse Aide (NA) Employee E7 stated that substantial/ maximal assistance requires two staff.

During an interview on 3/5/26, at 9:00 a.m., NA Employee E8 stated that substantial/maximal assistance requires two staff.

During an interview on 3/5/26, at 10:58 a.m., Therapy Manager Employee E9 stated that Resident R8 was not on caseload since 10/9/25, due to her inability to understand and follow commands and that care was identified to require two staff at all times due to her dementia progression.

During an interview on 3/5/26, at 10:28 a.m., the Nursing Home Administrator confirmed that the facility failed to identify and conduct a thorough investigation of an injury obtained during care to eliminate possible neglect for one of five residents (Resident R8). 28 Pa Code: 201.18 (e)(1)(2) Management.28 Pa Code: 201.29 (a)(c) Resident Rights.28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services.

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

During an interview on 3/6/26, at approximately 11:30 a.m. the Resident Nurse Assessment Coordinator confirmed that the above Minimum Data Set assessments were inaccurate.

During an interview on 3/6/26, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for five of nine residents. 28 Pa.

Code: 211.5(f) Clinical records.

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

Review of the facility policy Care Plans, Comprehensive Person-Centered dated 1/8/26, previously dated 1/14/25, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

Review of the clinical record indicated Resident R41 was admitted on [DATE].

Review of Resident R41's MDS dated [DATE], indicated diagnoses of dementia, depression, and chronic pain.

Review of Resident R41's comprehensive MDS dated [DATE], indicated psychotropic drug use was triggered in Section V: Care Area Assessment Summary.

Review of the CAA Worksheet included the question, Will Psychotropic Drug Use be addressed in the care plan? This question was documented as Yes.

Review of Resident R41's physician order dated 5/16/24, indicated to administer venlafaxine (an anti-depressant medication) 37.5 mg and 75 mg daily for depression.

Review of Resident R41's physician order dated 11/25/25, indicated to administer haloperidol 0.5mg every twelve hours PRN for agitation.

Review of Residents R41 care plan initiated 11/11/22, most recently revised 2/23/26, failed to include a plan of care developed for psychotropic drug use.

During an interview on 3/6/26, at approximately 12:00 p.m. the Nursing Home Administrator confirmed the facility failed to develop person-centered care plans for one of six residents. 28 Pa.

Code: 211.12 (d) (1) (2) (5) Nursing services.

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

During an observation there was a tan colored brief laying on the windowsill, and a package of size large briefs had been opened and Resident R26 showed that it was too small for her.

Resident R26's left eye appeared reddened.

During an observation of the [NAME] nursing unit medication cart, Resident R26 did not have eye drops identified in the cart.

During a review a latex allergy was indicated on Resident R26's clinical record and an order for Artificial Tears 2 drops both eyes twice per day and 1 drop both eyes every 6 hours as needed.

During an interview on 3/4/26, at 11:08a.m., Registered Nurse Employee E5 stated she did not know why the eye drops had been documented as given and were not available.

During an interview on 3/4/26, at 11:48 a.m., the Nursing Home Administrator confirmed that the facility failed to provide care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of two residents (Resident R26). 28 Pa.

Code 201.18 (b)(1) Management28 Pa.

Code 201.29(d) Resident Rights28 Pa.

Code 211.10 (c)(d) Resident Care policies28 Pa.

Code 211.12 (d)(1)(2)(3)(5) Nursing services

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

Review of the facility policy, Dressings, Dry/Clean dated 1/8/26, previously dated 1/14/25, indicated for staff to document that date and time the dressing was changed.

Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].

Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 12/9/25, included diagnoses of paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) and neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination).

Review of Section C: Cognitive Patterns indicated that Resident R1 was cognitively intact.

Review of Section M: Skin Conditions indicated the presence of a Stage Four pressure ulcer (Full-thickness skin and tissue loss).

Review of the plan of care dated 3/3/26, indicated that Resident R1 had actual skin impairment related to impaired mobility.

Included in the interventions was, Administer treatment per physician order.

Review of a physician's order dated 3/3/26, indicated that Resident R1 was to have dressing changes to sacral wound: Clean with acetic acid 1%, apply zinc oxide to peri wound, apply collagen, calcium alginate and apply abd (medical dressing) bid (twice daily) and prn (as needed).

During a dressing change observation completed on 3/5/26, at 2:00 p.m. the following was observed: The soiled dressing removed was noted to be dated 3/3/26, without a documented time or staff member who performed the dressing change. LPN Employee E4 used normal saline solution to clean Resident R4's wound. LPN Employee E3 suggested the use of soap and water to clean Resident R4's wound.LPN Employee E4 stated that Resident R4's dressing change was to be completed once daily.

Resident R4 responded to LPN Employee E4's comment and stated that he had not had twice daily dressing changes, in a very long time.

Review of Resident R4's Treatment Administration Record (TAR) for March 2026, on 3/5/26, at 2:25 p.m. confirmed that Resident R4 was to receive twice daily dressing changes and confirmed that LPN Employee E2 had documented that she completed both the morning and evening dressing changes on 3/4/26.

During an interview on 3/5/26, at 2:30 p.m. the Nursing Home Administrator and the Director of Nursing were informed that the dressing removed from Resident R4 during the dressing change observation on 3/5/26, was dated 3/3/26, and that incorrect information was entered on the TAR documenting that dressing changes were completed by LPN Employee E2 on 3/4/26, for both day and evening dressing change.

During an interview on 3/6/26, at approximately 12:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to make certain residents were provided necessary treatments and services, consistent with professional standards of practice, for a pressure ulcer for one of three residents. 28 Pa.

Code: 211.12(d)(5) Nursing Services.

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

During an interview on 3/4/25, at 3:00 p.m., Registered Nurse Employee E6 and Nurse Aide (NA) Employee E7 stated that substantial/ maximal assistance requires two staff.

During an interview on 3/5/26, at 9:00 a.m., NA Employee E8 stated that substantial/maximal assistance requires two staff.

During an interview on 3/5/26, at 10:58 a.m., Therapy Manager Employee E9 stated that Resident R8 was not on caseload since 10/9/25, due to her inability to understand and follow commands and that care was identified to require two staff at all times due to her dementia progression.

During an interview on 3/5/26, at 10:28 a.m., the Nursing Home Administrator confirmed that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents for one of two residents (Resident R8). 28 Pa.

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

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

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

During an interview on 3/6/26, at approximately 10:30 a.m. the Nursing Home Administrator confirmed that the facility was unable to locate the MRRs for Residents R7, R41 and R22.

During an interview on 3/6/26, at approximately 12:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documentation of medication regimen reviews completed at least monthly for three of seven residents. 28 Pa.

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

Code 211.5(f) Medical records. 28 Pa.

Code: 211.12(d)(1)(3)(5) Nursing services.

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

professional principles; and all drugs and biologicals must be stored in locked compartments,

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on

ensure opened vials were labeled in accordance with currently accepted professional principles for one of one medication rooms([NAME] Medication Room) and medications obtained from the emergency machine for a resident were labeled in accordance with currently accepted professional standards for one of two medication carts ( [NAME] Medication Cart).

Findings include:Review of facility policy Medication Labeling and Storage, dated 1/8/26, with a previous review date of 1/14/25, indicated multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Labeling of medications dispensed by the pharmacy is consistent with applicable federal and state requirements.During observation of the [NAME] medication storage room on 3/4/26, at 11:08 a.m., revealed one vial of tuberculosis purified protein derivative solution (PPD - used to determine resident or staff exposure or infection with tuberculosis) opened with no opened date written on the vial or the box that contained the vial.

During an interview on 3/4/26, at 11:08 a.m., Registered Nurse Employee E5 confirmed that the one vial appeared accessed and that there was not an open date on the vial or box of the PPD solution.During an observation on 3/5/26, at 7:40 a.m., Registered Nurse Employee E4 removed a Nicotine Patch box containing an opened undated patch and stated that was the patch used for Resident R49. RN Employee E4 confirmed the box and parch were unlabeled and undated.29 Pa code 211.12(d)(1)(5) Nursing services

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

the food and nutrition service, including a qualified dietician.

failed to employ a qualified Food Service Director to manage the daily operations of the Dietary

interview on 3/4/26, at 9:40 a.m., the Dietary Supervisor stated she was not certified and that the Dietitian only works two days a week.

During an interview on 3/4/26, at 10:00 a.m., the Nursing Home Administrator stated that the Registered Dietitian (RD) was not employed full time she comes two times a week.The RD was not on-site full time to oversee the operation of the kitchen in the absence of a full time qualified dietary manager.

During an interview on 3/4/26, at 10:12 a.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide documented evidence that Dietary Manager Employee E1 met the qualifications for the position of Food Service Director.Pa Code: 201.18(e)(6) Management.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

serve food in accordance with professional standards.

facility failed to properly store food products in the Main Kitchen, which created the potential for

Receiving and Storage dated 1/8/26, indicated that all food items will be received and stored in a manner that complies with safe food handling practices.During an observation of the main kitchen on 3/4/26, at 9:40 a.m., revealed food being stored directly under the fans of the deep freezer with ice buildup and approximately three inches from the ceiling of the deep freezer.

During an interview on 3/4/26, at 9:43 a.m., the Dietary Supervisor Employee E10 confirmed that the facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness.Pa. 28 Code: 211.6(c)(d)(f) Dietary services.

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

dressing changes were completed by LPN Employee E2 on 3/4/26, for both the day and evening

treatments for two of four residents. 28 Pa.

Code: 211.5(f)(g)(h) Clinical records.

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

the facility failed to ensure an environment free from the spread of infection for five of twelve

Responsibility of licensee.28 Pa.

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

Code: 211.10(c)(d)

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

(April 2025 -March 2026).

Findings include:Review of facility policy Antibiotic Stewardship Program

will focus on monitoring the use of antibiotics, improving antibiotic use by avoiding unnecessary or inappropriate antibiotics.

The antibiotic stewardship process will be overseen and managed by the Infection Preventionist who works collaboratively with the medical director, pharmacist, nursing and administrative leadership.

Review of the facility's Infection Control surveillance for April 2025- March 2026, failed to include documentation to indicate that antibiotic monitoring was completed.During an interview on 4/6/26, at 12:00 p.m., the Nursing Home Administrator confirmed that the facility failed to implement an antibiotic stewardship program for 12 of 12 months (April 2025-March 2026).28 Pa.

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

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

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

Review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE].

Review of Resident R5's immunization documentation record did not include that the Pneumococcal vaccine was offered since admission.

Review of the clinical record indicated that Resident R8 was admitted to the facility on [DATE].

Review of Resident R8's immunization documentation record did not include that the Pneumococcal vaccine was offered since admission.

Review of the clinical record indicated that Resident R14 was admitted to the facility on [DATE].

Review of Resident R14's immunization documentation record did not include that the Pneumococcal vaccine was offered since admission.

Review of the clinical record indicated that Resident R16 was admitted to the facility on [DATE].

Review of Resident R16's immunization documentation record did not include that the Pneumococcal vaccine was offered since admission.

Review of the clinical record indicated that Resident R12 was admitted to the facility on [DATE].

Review of Resident R12's immunization documentation record did not include that the Pneumococcal vaccine was offered since admission.

Review of the clinical record indicated that Resident R7 was admitted to the facility on [DATE].

Review of Resident R7's immunization documentation record did not include that the Pneumococcal vaccine was offered since admission.

Review of the clinical record indicated that Resident R31 was admitted to the facility on [DATE].

Review of Resident R31's immunization documentation record did not include that the Pneumococcal vaccine was offered since admission.

The last Pneumococcal vaccine had been given in 2013, according to the medical record.

During an interview on 3/6/26, at 2:10 p.m., the Nursing Home Administrator confirmed that the facility failed to offer pneumococcal disease vaccines in accordance with facility policy to seven of nine residents whose vaccines were reviewed. (Residents R5, R8, R14, R16, R12, R7 and R31).

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102

Observation of the restroom revealed no emergency call light or call cord attached for emergency use.

During an observation on 3/4/26, at approximately 10:30 a.m. the staff restroom on the Garden nursing unit was unlocked, with the key hanging off the door knob, accessible to residents.

Observation of the restroom revealed no emergency call light or call cord attached for emergency use.

During an observation on 3/5/26, at approximately 9:45 a.m. the staff restroom on the [NAME] nursing unit was unlocked, with the key hanging on a magnetic hook approximately waist height, inside the restroom.

Observation of the restroom revealed no emergency call light or call cord attached for emergency use.

During an observation on 3/6/26, at approximately 9:30 a.m. the staff restroom on the [NAME] nursing unit was unlocked, with the key hanging on a magnetic hook approximately waist height, inside the restroom.

Observation of the restroom revealed no emergency call light or call cord attached for emergency use.

During an observation on 3/6/26, at approximately 11:30 a.m. the staff restroom on the Garden nursing unit was unlocked, with the key hanging off the door knob, accessible to residents.

Observation of the restroom revealed no emergency call light or call cord attached for emergency use.

During an interview on 3/6/26, at approximately 10:28 a.m. the Nursing Home Administrator confirmed the facility failed to maintain an effective call system for two of five restrooms accessible to residents. 28 Pa.

Code 201.14 (a) Responsibility of licensee28 Pa.

Code 201.18 (b) (1) Management

395698 03/06/2026

Meadowcrest Rehabilitation & Healthcare Center 1200 Braun Road Bethel Park, PA 15102