Deficiencies (last 3 years)
Deficiencies (over 3 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
226% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 22, 2025
Visit Reason
The inspection was conducted to investigate complaints related to failure in following a resident's care plan regarding male caregivers, inadequate nutrition and hydration leading to actual harm, and failure to maintain accurate medical records.
Complaint Details
The investigation was complaint-driven, focusing on allegations of abuse related to male caregivers, inadequate nutrition and hydration causing harm, and inaccurate medical recordkeeping. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure a resident did not receive care from male aides as per care plan, failed to assess and intervene adequately for a resident's nutritional and hydration needs resulting in hospitalization, and failed to maintain accurate medical records documenting an injury incident.
Deficiencies (3)
Failed to follow a resident's care plan by allowing male caregivers despite resident's request.
Failed to provide adequate nutrition and hydration to a resident, resulting in actual harm and hospitalization.
Failed to maintain accurate medical records for a resident, including documentation of injury.
Report Facts
Residents reviewed: 15
Residents reviewed: 11
Resident weight: 123
Resident height: 69
Ideal body weight: 160
Caloric needs: 1500
Caloric needs: 1950
Fluid needs: 1500
Fluid needs: 1800
Nutritional supplement intake: 557
Nutritional supplement intake: 536
Nutritional supplement intake: 437
Nutritional supplement intake: 951
Nutritional supplement intake: 634
Nutritional supplement intake: 694
Nutritional supplement intake: 664
Nutritional supplement intake: 399
Nutritional supplement intake: 457
Nutritional supplement intake: 279
Nutritional supplement intake: 634
Nutritional supplement intake: 288
Nutritional supplement intake: 467
Nutritional supplement intake: 240
Nutritional supplement intake: 634
Nutritional supplement intake: 240
Blood chloride level: 128
Blood sodium level: 170
Blood urea nitrogen (BUN): 48
Nutritional supplement dosage: 4
Nutritional supplement dosage: 8
IV fluid rate: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E9 | Aide | Assigned male aide who provided care to Resident R2 against care plan |
| Employee E5 | Registered Dietitian | Confirmed last nutritional assessment and lack of notification about dietary consult |
| Employee E7 | Nurse Practitioner | Ordered nutritional assessments, IV fluids, and hospital transfer for Resident CL1 |
| Employee E6 | Licensed Nurse | Attempted IV insertion and documented nursing notes for Resident CL1 |
| Employee E14 | Registered Nurse, Unit Supervisor | Assessed Resident R1 after injury incident and confirmed injury |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The inspection was conducted to assess compliance with physician orders and care standards, specifically reviewing the facility's adherence to Do Not Resuscitate (DNR) orders for residents.
Findings
The facility failed to follow physician orders regarding the DNR status of one resident (Resident R2), resulting in inappropriate resuscitation efforts despite a documented DNR order. This failure led to the resident's death and was confirmed by the Director of Nursing.
Deficiencies (1)
Failure to follow physician orders for Resident R2's DNR status, resulting in inappropriate resuscitation efforts.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E5 | Licensed Nurse | Named in nursing progress note documenting resident condition and response. |
| Director of Nursing | Confirmed facility failed to implement Physician Order pertaining to Resident R2's DNR status. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 11, 2025
Visit Reason
The inspection was conducted following complaints regarding improper resident discharge documentation, failure to notify residents and representatives of transfers, and inadequate care planning for residents exhibiting aggressive behaviors.
Complaint Details
The complaint investigation found substantiated issues related to improper discharge documentation for Resident R523, failure to notify Resident R136's representative and Ombudsman of a facility-initiated transfer, and inadequate care planning for Resident R325's aggressive behavior.
Findings
The facility failed to document appropriate discharge reasons for a resident transferred to the hospital without physician order or notification, failed to notify the resident's representative and the Ombudsman of the transfer, and failed to develop a comprehensive care plan with measurable objectives for a resident exhibiting aggressive behavior towards others.
Deficiencies (3)
Failed to ensure appropriate discharge documentation and physician notification for resident transfer to hospital.
Failed to provide timely notification to resident, representative, and Ombudsman before transfer or discharge.
Failed to develop and implement a comprehensive care plan with measurable objectives for a resident exhibiting aggressive behaviors.
Report Facts
Clinical records reviewed: 35
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E8 | Admission Director | Interviewed regarding resident discharge due to insurance paperwork |
| Employee E15 | Nurse Aide | Provided statement regarding altercation between residents R325 and R72 |
| Employee E14 | Nurse Aide | Provided statement regarding altercation between residents R325 and R46 |
Inspection Report
Routine
Deficiencies: 10
Date: Apr 11, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident discharge documentation, notification of transfers, PASRR screening, care planning, medication administration, pain management, food service, therapeutic diets, and resident rights including arbitration agreements.
Findings
The facility was found deficient in multiple areas including failure to document appropriate discharge reasons and notify representatives of transfers, incomplete PASRR screening, inadequate care plans for residents with aggressive behaviors, failure to revise care plans accurately, missed medication doses, inadequate pain management due to delayed medication delivery, serving food at improper temperatures and incorrect therapeutic diets, and failure to ensure resident capacity for signing arbitration agreements.
Deficiencies (10)
Failure to document an appropriate discharge reason and provide required notification for resident transfers to hospital.
Failure to complete PASRR screening appropriately according to resident assessment.
Failure to provide timely notification to resident and representatives before transfer or discharge.
Failure to develop a comprehensive care plan with measurable objectives for resident exhibiting aggressive behaviors.
Failure to revise resident care plans accurately based on assessments and diagnoses.
Failure to administer medication as ordered by the physician, resulting in missed doses.
Failure to provide safe, appropriate pain management for residents due to delayed medication delivery and missed doses.
Failure to provide food and drink that was palatable and served at safe and appetizing temperatures.
Failure to ensure therapeutic diets prescribed by attending physician were provided correctly to resident.
Failure to ensure resident had capacity to understand terms of binding arbitration agreement prior to signing.
Report Facts
Missed medication doses: 2
Missed medication doses: 4
Missed medication doses: 10
Food temperature: 109
Food temperature: 103.5
Food temperature: 116
Food temperature: 61
Food temperature: 53.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E8 | Admission Director | Interviewed regarding resident discharge and arbitration agreement procedures. |
| Employee E9 | Unit Manager | Confirmed missed medication doses for Resident R175. |
| Employee E2 | Director of Nursing | Confirmed missed medication doses and narcotic delivery delays for Residents R9 and R132. |
| Employee E6 | Social Worker | Confirmed PASRR assessment deficiencies for Resident R184. |
| Employee E15 | Nurse Aide | Provided statement regarding resident altercation involving Resident R325. |
| Employee E3 | Food Service Director | Conducted food temperature observations during test tray. |
| Employee E10 | Director of Rehabilitation | Confirmed therapeutic diet order discrepancies for Resident R210. |
| Employee E11 | Speech Language Pathologist | Provided discharge summary and diet recommendations for Resident R210. |
Inspection Report
Deficiencies: 1
Date: Jun 10, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of quality in medication orders, specifically regarding a non-physician practitioner's prescribing practices for one resident receiving antidiabetic medication.
Findings
The facility failed to ensure that a non-physician practitioner maintained professional standards of quality care for one resident (Resident R 96) related to the ordering and administration of Ozempic at an incorrect dosage. The resident experienced pain during medication administration and nausea after the first dose, leading to a dose reduction and additional medication orders. The prescribing error was confirmed by the non-physician practitioner.
Deficiencies (1)
Failure to ensure care and services were provided in accordance with professional standards of practice for one resident regarding proper medication order by a non-physician practitioner.
Report Facts
Residents reviewed: 35
Resident blood sugar levels: 260
Resident blood sugar levels: 350
Resident blood sugar levels: 250
A1c value: 6.4
Medication dose: 2
Medication dose: 0.25
Date of first dose administration: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Non-physician practitioner | Employee E 18 who ordered the medication and confirmed the dosing error |
Inspection Report
Routine
Deficiencies: 15
Date: Jun 10, 2024
Visit Reason
The inspection was conducted based on observations, resident and staff interviews, and clinical record reviews to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including maintaining a safe and clean environment, medication management including narcotic discrepancies and improper medication orders, failure to conduct thorough investigations of incidents, inadequate care planning for residents' needs, failure to monitor adverse effects of medications, improper infection control practices, inaccurate meal tray provisions, and failure to implement an effective antibiotic stewardship program.
Deficiencies (15)
Failed to maintain a safe, clean, homelike environment on three of five nursing units including issues with cleanliness, odor, and storage in shower rooms.
Failed to ensure a resident was free from misappropriation related to missing medication for one of 35 residents reviewed.
Failed to conduct a complete and thorough investigation of an alleged violation for one of 35 residents reviewed.
PASRR screening was not appropriately completed according to the resident assessment for two of three residents reviewed.
Did not develop a baseline care plan for a newly admitted resident with history of drug abuse.
Failed to develop and implement a comprehensive care plan related to swallowing difficulties and unwanted behaviors during mealtime for two residents.
Failed to ensure care and services were provided in accordance with professional standards of practice for one resident regarding proper medication order.
Failed to ensure physician orders were followed related to insulin administration for two residents and adaptive equipment for one resident.
Failed to provide accurate meal trays and food products based on resident preferences for three residents.
Failed to establish and maintain an infection prevention and control program to prevent transmission of multidrug-resistant organisms and ensure hand hygiene during medication administration.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents.
Failed to provide appropriate care to maintain and/or improve range of motion and positioning for a resident with limited range of motion.
Failed to ensure accurate accounting of controlled drugs in one medication storage room.
Failed to ensure residents' drug regimen was free from unnecessary drugs related to antipsychotic medication without adequate monitoring.
Failed to maintain an effective antibiotic stewardship program including monitoring antibiotic usage for four months reviewed.
Report Facts
Medication discrepancy: 29
Residents treated with antibiotics: 73
Blood sugar level: 413
Blood sugar level: 459
Medication dose: 2
Medication dose: 0.25
Medication volume discrepancy: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E28 | Housekeeper | Mentioned in relation to dried tube feeding substance on floor. |
| Employee E25 | Housekeeping Director | Confirmed removal of dried tube feeding substance and stained toilets. |
| Employee E3 | Licensed Unit Manager | Confirmed observations in shower room on E unit. |
| Employee E6 | Regional Maintenance Director | Confirmed stained toilets and cleaning methods. |
| Employee E12 | Licensed Nurse | Involved in narcotic counts and medication administration related to missing oxycodone. |
| Employee E13 | Licensed Agency Nurse | Involved in narcotic counts and medication administration related to missing oxycodone. |
| Employee E14 | Licensed Agency Nurse | Administered oxycodone doses and involved in narcotic counts. |
| Employee E15 | Licensed Nurse | Involved in narcotic counts and medication administration related to missing oxycodone. |
| Employee E26 | Registered Nurse | Reported choking incident and incomplete investigation. |
| Employee E29 | Assistant Director of Nursing | Confirmed lack of baseline care plan and monitoring of antipsychotic medication. |
| Employee E10 | Director of Social Work | Confirmed inaccurate PASRR assessments. |
| Employee E17 | Speech Therapist | Recommended no straws for resident at risk of aspiration. |
| Employee E18 | Non-physician Practitioner | Ordered incorrect dose of Ozempic medication. |
| Employee E20 | Nurse Aide | Confirmed improper heel offloading. |
| Employee E30 | Licensed Practical Nurse | Confirmed improper heel offloading. |
| Employee E31 | Rehab Director | Confirmed lack of intervention for head/neck positioning. |
| Employee E32 | Licensed Practical Nurse | Noted discrepancy in lorazepam liquid medication count. |
| Employee E33 | Infection Control Nurse | Confirmed lack of antibiotic usage review. |
| Employee E5 | Licensed Dietician | Confirmed meal tray did not reflect resident's food preference. |
| Employee E9 | Nursing Aid | Confirmed missing food items on meal trays. |
| Employee E21 | Unit Manager | Confirmed no straws allowed and instructed hand hygiene. |
| Employee E22 | Nurse | Observed not sanitizing hands between medication administration. |
| Employee E25 | Nurse | Observed not sanitizing hands between medication administration. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 10, 2024
Visit Reason
The inspection was conducted following a complaint investigation regarding the facility's failure to maintain appropriate supervision for residents with suicidal ideations, specifically Residents R1 and R6.
Complaint Details
The complaint investigation found that Resident R1 was left unattended in the hospital triage area despite orders for 1:1 supervision, and Resident R6 was observed alone without required 1:1 supervision. The facility failed to ensure proper handoff and supervision as required.
Findings
The facility failed to maintain 1:1 supervision for two residents with suicidal ideations as ordered, resulting in Resident R1 being left unattended in a hospital triage area and Resident R6 being observed alone without supervision in her room.
Deficiencies (1)
Failure to maintain appropriate supervision for residents with suicidal ideations, including leaving Resident R1 unattended in hospital triage and Resident R6 alone without 1:1 supervision.
Report Facts
Deficiencies cited: 1
BIMS score: 12
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E3 | Nurse Practitioner | Assessed Resident R1 and documented suicidal ideation |
| Employee E4 | Psych Nurse Practitioner | Evaluated Resident R1 and determined need for 1:1 supervision |
| Employee E5 | Van Driver | Transported Resident R1 to hospital and left resident unattended in triage area |
| Employee E6 | Licensed Nurse | Interviewed and observed Resident R6 without required 1:1 supervision |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 5, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of verbal, physical, and psychological abuse of a resident (Resident R1) by nursing staff at Meadowview Rehabilitation and Nursing Center.
Complaint Details
The complaint investigation substantiated that nurse aide Employee E4 verbally abused Resident R1 using profane language, roughly handled and pushed the resident, and physically struck Resident R1 in the chest causing injuries. The incident was witnessed by other staff and documented via video footage and statements. Immediate Jeopardy was identified on January 4, 2024, and lifted on January 5, 2024, after corrective actions were implemented.
Findings
The facility failed to protect Resident R1 from abuse by a nurse aide who verbally abused, roughly handled, and physically struck the resident, causing injuries and signs of fear. The abuse was documented through video footage, staff interviews, and clinical records. Immediate Jeopardy was identified and later lifted after corrective actions were implemented.
Deficiencies (2)
Failure to protect Resident R1 from verbal, physical, and psychological abuse by nursing staff, resulting in immediate jeopardy.
Failure of Nursing Home Administrator and Director of Nursing to effectively manage the facility to ensure resident protection from abuse.
Report Facts
BIMS score: 2
Date of incident: Dec 21, 2023
Date survey completed: Jan 5, 2024
Number of residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E4 | Nurse Aide | Perpetrator of verbal and physical abuse against Resident R1; terminated following the incident. |
| Employee E5 | Nurse Aide | Witnessed the abuse incident, reported it to the Director of Nursing, and provided a detailed statement. |
| Employee E2 | Director of Nursing | Received abuse report, involved in investigation and corrective action implementation. |
| Employee E1 | Nursing Home Administrator | Confirmed abuse incident and termination of Employee E4; failed to effectively manage facility contributing to Immediate Jeopardy. |
| Employee E3 | Assistant Director of Nursing | Confirmed abuse incident and handling of Resident R1 by Employee E4. |
| Employee E7 | Nursing Supervisor | Was on break during incident, later informed and involved in follow-up. |
| Employee E8 | Licensed Nurse | Witnessed parts of the incident and provided statements. |
| Employee E23 | Nurse Aide | Witnessed Employee E5's reaction to the abuse and assisted in reporting. |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 11, 2023
Visit Reason
The inspection was conducted to assess compliance with care and service requirements, including follow-up on medical appointments and the safety and cleanliness of the facility environment.
Findings
The facility failed to ensure that a resident (Resident R3) received needed follow-up medical appointments due to transportation issues, causing delays in recommended surgical clearance. Additionally, the facility failed to maintain a clean, safe, and functional environment in four of five central bathing rooms and the boiler room, with issues such as rust, corrosion, water leaks, and clutter.
Deficiencies (2)
Failure to provide appropriate treatment and care related to follow-up medical appointments for surgery clearance for Resident R3.
Failure to maintain a clean, safe, and functional environment in four of five central bathing rooms and the boiler room.
Report Facts
Residents affected: 1
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Director of Nursing | Confirmed missed nephrology appointment due to transportation issues |
| Employee E10 | Maintenance Director | Confirmed findings related to boiler room conditions |
| Employee E12 | Infection Preventionist | Confirmed findings related to central bathing rooms |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Aug 31, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, dietary services, medical record maintenance, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive person-centered care plans for residents with PTSD and communication needs, improper oxygen therapy administration, failure to implement psychiatry recommendations, inadequate medication storage and disposal, failure to provide special eating utensils, unsafe food preparation and sanitation practices, incomplete medical record documentation, and ineffective pest control.
Deficiencies (8)
Failed to develop and implement comprehensive person-centered care plans related to PTSD and communication for residents.
Failed to ensure oxygen therapy was administered per physician's orders for one resident.
Failed to implement psychiatry recommendations for one resident.
Failed to ensure all drugs and biologicals were properly stored and disposed of in locked medication rooms on two nursing units.
Failed to provide special eating equipment and utensils for one resident.
Failed to provide palatable, attractive, and safely prepared food at appropriate temperatures; failed to ensure dishes were cleaned under sanitary conditions.
Failed to maintain complete and accurate documentation related to resident refusals and weights for two residents.
Failed to maintain an effective pest control program on three nursing units.
Report Facts
Residents reviewed: 38
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 2
Parts per million: 0
Parts per million: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E30 | Licensed Nurse | Named in communication deficiency related to Resident R189 |
| Employee E31 | Nurse Aide | Named in communication deficiency related to Resident R189 |
| Employee E32 | Unit Manager | Interviewed regarding communication and oxygen therapy deficiencies |
| Employee E33 | Social Services Director | Interviewed regarding communication and care planning deficiencies |
| Employee E20 | Licensed Nurse | Interviewed regarding medication room security deficiencies |
| Employee E21 | Licensed Nurse | Interviewed regarding medication storage and disposal deficiencies |
| Employee E22 | Licensed Nurse | Witnessed destruction of expired medication blister card |
| Employee E34 | Food Service Manager | Interviewed regarding food safety and sanitation deficiencies |
| Employee E35 | Supervisor | Interviewed regarding food safety deficiencies |
| Employee E36 | Cook | Interviewed regarding food safety deficiencies |
| Employee E17 | Registered Dietician | Interviewed regarding special eating equipment deficiency |
| Employee E13 | Unit Manager | Interviewed regarding documentation deficiencies for resident refusals and weights |
| Employee E18 | Director of Housekeeping | Interviewed regarding pest control deficiencies |
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