Meadowview Rehabilitation And Nursing Center

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Based upon review of resident records, and interviews with residents and staff determined the facility failed to follow a resident's care plan consistent with the resident's rights that meets a resident's mental and psychosocial needs by failing to ensure one resident does not receive male care givers as indicated of 15 resident records reviewed (Resident Resident R2). Findings include:Resident Resident R2 was initially admitted to the facility June 2019 diagnosed with post traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event).Resident Resident R2's care plan dated September 23, 2023, for ineffective coping due to past traumatic events that triggers include male care givers. Per the sister's request is not to have a male aide.Review of documentation received from the facility stated on May 1, 2025, Resident Resident R2 made allegations of abuse when a male aide, Employee E9 was assigned to the resident.Interview with Employee Resident R9 on October 21, 2025, at 3:00 p.m. confirmed the aide was assigned Resident Resident R2 on May 1, 2025, and stated he was aware Resident Resident R2 was not to receive care from male aides. Interview with Resident Resident R2 on October 22, 2025, at 10:00 a.m., confirmed the resident did not want male aides to assist with care. 28 Pa Cre 211.109d) Resident care policies28 PA. Code 211.12(d)(1)(5) Nursing services

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:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Meadowview Rehabilitation and Nursing Center

9209 Ridge Pike White Marsh, PA 19128

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 0692 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

nurse as well as another UM attempted to insert line, resident resistive to receiving line placed. Resident continuously pulled away and became combative. Nursing attempted to re-educate resident on the need of fluids and risk of refusal/ resident stated understanding and continued to pull back . HOB (Head of the bed) elevated to prevent SOB (shortness of breath). Re-position ineffective .STAT (immediate) Potassium per NP order and resident spit out medication. NP made aware of above and gave verbal order to send resident to [hospital]. Interview with the Licensed nurse, Employee E6, at 11:00 a.m., on October 21, 2025, confirmed

the nursing staff were not able to follow the nurse practitioner's orders. The licensed nurse confirmed that

the nurse practitioner then gave orders for Resident CL1 to be sent to the hospital emergently. Review of Resident CL1's hospital record for October 9, 2025, revealed Resident CL1 presented from the facility with hypernatremia (high sodium level in the blood) and dehydration. The facility failed to assess, monitor, and implement interventions to ensure Resident CL1 maintained optimal nutrition and hydration. This failure resulted in actual harm to Resident CL1 who was not receiving sufficient fluid and caloric intake resulting in abnormal blood values, requiring transfer to hospital and admission with diagnoses of hypernatremia and dehydration. 28 PA. Code:201.14(a)(b) Responsibility of licensee28 PA. Code: 201.18(b)(1) Management28 PA. Code:211.10(c) Resident care policies28 PA. Code:211.12(c)(d)(1)(2)(3)(5) Nursing services

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Meadowview Rehabilitation and Nursing Center

9209 Ridge Pike White Marsh, PA 19128

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with residents and staff, review of clinical records, facility documentation and in accordance with accepted professional standards and practices, the facility failed to maintain medical records that were accurately documented for one of 15 resident records reviewed (Resident Resident R1).Findings include:Review of Resident Resident R1's clinical records revealed the resident was alert and oriented and admitted to the facility on [DATE REDACTED], diagnosed with atherosclerotic heart disease.Review Resident Resident R1's nursing note dated October 13, 2025, indicated the resident said the aide pushed her while putting her in bed. The resident was noted with

a large hematoma (blood leaks outside the blood vessels, usually due to injury) to her forehead and was given an icepack.Review of documentation received from the facility indicated the resident's skin was intact with no discoloration.Interview on October 22, 2025, at 4:00 p.m. unit supervisor, registered nurse, Employee E14 worked the night of the incident and assessed Resident Resident R1 immediately afterwards. E14 confirmed the injury on the resident's forehead. 28 Pa. Code 211.12(d)(1) Nursing services

Event ID:

Facility ID:

If continuation sheet