Meadowview Rehabilitation And Nursing Center
Inspection Findings
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, reviews of clinical records, facility policies and procedures, and interviews with staff and residents, it was determined that the facility failed to follow physician orders for one of eight residents' clinical records reviewed. (Resident Resident R2)Findings include:Review of Resident Resident R2's clinical record revealed
the resident was admitted to the facility on July10, 2025, with diagnosis of Combined Systolic and Diastolic Heart Failure (a condition where the heart has difficulty both pumping blood out [systolic dysfunction] and filling with blood [diastolic dysfunction], Pericardial Effusion (a condition where excess fluid accumulates in
the pericardium, the sac-like structure that surrounds the heart), Pleural Effusion (a condition where excess fluid accumulates in the space between the lungs [pleural cavity and the chest wall], and Thrombocytopenia (a condition characterized by a low platelet count in the blood. Platelets are essential for blood clotting, so their deficiency can lead to excessive bleeding and bruising).Review of Resident Resident R2's clinical record revealed a form, Pennsylvania Orders for Life Sustaining Treatment (POLST), dated [DATE REDACTED], that indicated
the resident's code status as DNR (Do Not Attempt Resuscitation). Review of Resident Resident R2's electronic clinical record revealed a physician order, dated [DATE REDACTED], indicated; Do Not Resuscitate (DNR).Review of the Nursing Progress note for Resident Resident R2, by a Licensed Nurse, Employee E5, dated [DATE REDACTED], indicated as follows: Around 0300, during rounds, [Resident Resident R2's] roommate notified this nurse that resident did not look well. Upon entering room, [Resident Resident R2] was noted with slow shallow breathing. SpO2: 84 (SpO2 is oxygen saturation, it is a measurement of the percentage of hemoglobin in the blood that is saturated with oxygen, for a healthy individual, the normal SpO2 should be between 96% to 99%). [Resident Resident R32] was given with Oxygen via mask. Nursing supervisor was called to assess resident. Before nursing supervisor could enter unit, [Resident Resident R2] was noted with foam coming from mouth and unresponsive. Code Blue/911 was immediately called (Code Blue refers to a hospital medical emergency requiring immediate resuscitation for
a patient in cardiac or respiratory arrest). CPR initiated by nursing staff until/during paramedics' arrival (CPR, or cardiopulmonary resuscitation, is a life-saving emergency procedure performed when a person's heart has stopped beating or their breathing has ceased). [Resident Resident R2] was given 4-5 rounds of epi but was unsuccessful (epi is a medical abbreviation for epinephrine, also known as adrenaline. In a cardiac arrest, epinephrine is administered to increase blood pressure and heart rate, which helps improve blood flow to the heart and brain). TOD (Time of Death) was called by Physician. Call was placed to emergency contact. The nurse spoke with resident's sister to inform family of resident's untimely passing and for further arrangements for pick-up.On [DATE REDACTED], at 1:22 p.m., interview with the Director of Nursing confirmed that the facility failed to implement the Physician Order pertaining to Resident Resident R2's code status/ DNR status.28 Pa Code 201.18(a)(b)(1)(3) Management28 Pa Code 211.12(d)(5) Nursing services
Residents Affected - Few
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 REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
MEADOWVIEW REHABILITATION AND NURSING CENTER in WHITE MARSH, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WHITE MARSH, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MEADOWVIEW REHABILITATION AND NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.