Meadowcrest Rehabilitation & Healthcare Center

Inspectors wroteBased on review of employee qualification and staff interview it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 out of 12 months (April 2025 through March 2026).

Inspectors wroteBased on a review of facility policy, observations and staff interview it was determined that the facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness in one of one deep freezer. Findings Include:Review of the facility policy Food 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. [...]

Inspectors wroteBased on a review facility policy, clinical records, observations, and resident and staff interviews, it was determined that the facility failed to ensure an environment free from the spread of infection for five of twelve residents (Residents R1, R4, R6, R12, and R33) and failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for 12 of 12 months (April 2025 through March 2026).

Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for 12 of 12 months (April 2025 -March 2026).

Inspectors wroteBased on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to ensure that resident's medication regime was free from unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medication for four of seven residents (Resident R22, R4, R7, and R41).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an injury obtained during care to eliminate possible neglect for one of two residents (Resident R8).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for six of nine residents (Resident R7, R8, R16, R17, R41 and R8).

Inspectors wroteBased on resident interview, observations, clinical record review, and staff interviews, it was determined 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).

Inspectors wroteBased on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to make certain residents were provided necessary treatments and services, consistent with professional standards of practice, for a pressure ulcer (PU/PI - injuries to the skin and underlying tissues resulting from prolonged pressure on the skin) for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents for one of two residents (Resident R8).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to provide documentation of medication regimen reviews (MRR) completed at least monthly for three of seven residents (Resident R7, R41 and R22).

Inspectors wroteBased on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to appropriately document treatments for two of four residents (Residents R4 and R1).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined 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).

Inspectors wroteBased on facility observations and staff interview, it was determined that the facility failed to maintain an effective call system for two of five restrooms accessible to residents.

Inspectors wroteBased on review of facility policy, resident records, and resident and staff interview it was determined that the facility failed to maintain the privacy and dignity of one of six residents (Residents R3).

Inspectors wroteBased on a review facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop person-centered care plans for one of six residents (Resident R41).

Inspectors wroteBased on observation, facility policy review, and staff interviews, it was determined that the facility failed to 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).

Inspectors wroteBased on observations and staff interview, it was determined the facility failed to post contact information for the Medicaid Fraud Unit on two of two nursing units ([NAME] and Garden nursing units).

Inspectors wroteBased on observations and staff interview, it was determined 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 ([NAME] and Garden nursing units).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to post the most recent Federal or State survey results for one of one survey books observed (located in main entrance lobby). Findings Include: Observation of the survey binder located in the main entrance lobby on 3/4/26, at 1:30 p.m, revealed the most recent survey results present were dated 9/11/24. Review of the facility's survey history revealed surveys dated: 1/8/25, 4/30/25, 6/11/25, 7/28/25, 9/3/25, 11/4/25, 12/2/25, 1/14/26, and 2/12/26. 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.

Inspectors wroteBased on a review of facility provided policies and documentation, clinical records, and resident, family, and staff interviews, it was determined that the facility failed to protect residents from resident-to-resident sexual abuse. This failure resulted in a resident with a known history of sexually inappropriate behavior involving non-consenting residents, which created an Immediate Jeopardy situation for one of 44 residents (Resident R2).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for the one of five residents (Residents R1).

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to protect residents from resident-to-resident sexual abuse. This failure resulted in a resident with a known history of sexually inappropriate behavior engaging a non-consenting resident for one of 44 residents (Resident R2).

Inspectors wroteBased on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions for when the individual is incapacitated) or conduct periodic review of instructions for two of five residents reviewed (Residents R1 and R2).

Inspectors wroteBased on a review of facility policy and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for four of ten months (July 2025 through October 2025).

Inspectors wroteBased on a review of clinical records, and staff interviews it was determined the facility failed to meet the dietary needs for three of eight residents (Resident R2, R3, and R4).

Inspectors wroteBased on a review of facility policy, resident choice menu selections, and meal observations, it was determined that the facility failed to provide resident selected menu items for four of nine residents (Resident R5, R6, R7, and R8).

Inspectors wroteBased on review of facility policies and documents, clinical records, and staff interviews, it was determined that the facility failed to provide prescribed treatment and services related to the care of a PICC line (peripherally inserted central catheter, a long, thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) for one of two residents (Resident R1). The facility policy Midline Dressing Changes dated 1/4/25, indicated to Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. [...]

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

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

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

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

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

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

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for ten of ten staff members (Employees E1, E2, E3, E4, E5, E6, E7, E8, E9 and E10).

Inspectors wroteBased on review of the facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for five of six residents reviewed (Resident R1, R2, R12, R20, and R35) Findings Include: A review of the facility policy Advanced Directives reviewed 3/21/23 and 1/4/2024, indicated advance directives will be respected in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. [...]

Inspectors wroteBased on review of facility policy, observations and staff interviews, it was determined that the facility failed to maintain a clean, homelike environment on two of two nursing units ([NAME] Lane and Garden Lane) and failed to provide a homelike environment for seven of 21 residents of the Garden Lane nursing unit (Residents R24, R4, R22, R34, R25, R16 and R17).

Inspectors wroteBased on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members (Infection Preventionist) for three of four quarterly meeting (May 2023 through July 2023, August 2023 through October 2023, and November 2023 through January 2024). Findings Include: Review of the facility policy Quality Assurance and Process Improvement Committee (QAPI) reviewed 1/4/24, indicated that the facility will establish and maintain a QAPI committee that consists of the administrator, director of nursing, medical director, and infection control representative. [...]

Inspectors wroteBased on review of staff interview and facility documents, it was determined that the facility failed to provide training on behavioral health for three of ten staff members reviewed (Employees E4, E5 and E8). Findings Include: Review of the policy Inservice Training dated 1/4/24, with previous review date of 3/21/23, indicated it is the policy of this facility that all staff participate in regular in-service education upon hire and annually and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Trainings included for all existing and newly hired employees include but not limited to communication, abuse, neglect, etc, the facility QAPI program and behavioral health. [...]

Inspectors wroteBased on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of three residents (Resident R23).

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to prevent food items from being stored in a medication refrigerator in one of two medication rooms ([NAME] Nursing Unit).

Inspectors wroteBased on facility policy review, clinical record review, resident and staff interviews, it was determined that the facility failed to provide nephrostomy (drain from the kidney using a catheter tube) care and services consistent with professional standards of practice for one of three residents with indwelling catheters (Resident R1).