Health inspection·September 4, 2025

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility policy, the minutes from facility Resident Council meetings, and grievances lodged with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings and verbal grievances, including those voiced by four of four residents attending a resident group meeting (Residents 22, 29, 43, and 8) and failed to keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution.Findings include: A review of the facility's Grievance Policy last reviewed on July 29, 2025, indicated the residents', families, and their representatives have the right to voice grievances concerning care and treatment, behavior of staff or other residents or any concerns regarding their stay. Further stating the grievance official follow up on all concerns and grievances registered by any resident or resident representative. A review of the Minutes from a Resident Council meeting, which included a food committee review, dated June 4, 2025, revealed concerns from residents that snacks were not being provided in the evening. Review of grievances revealed no documented evidence of a grievance regarding this concern and no evidence of any corrective actions taken to address this issue. A review of the Minutes from Resident Council meetings dated July 2, 2025, revealed concerns from residents that call bells were not answered timely. A grievance was filed on July 2, 2025, regarding this concern. Review of this grievance revealed no follow up was completed with the residents who raised this concern during resident council. Review of the food committee minutes reviewed during this resident council meeting revealed continued concerns with snacks not being provided in the evening. A review of the Minutes from a Resident Council meeting, which included a food committee review, dated August 7, 2025, revealed continued concerns from residents that snacks were not being provided in the evening. Review of grievances revealed no documented evidence of a grievance regarding this concern and no evidence of any corrective actions taken to address this issue. A group meeting conducted on September 3, 2025, at 10:30 a.m. with four residents (Residents 22, 29, 43, and 8) revealed unanimous reports that the facility failed to address their complaints regarding the timeliness of call bell response. Snacks continue to be a concern as well. Resident 43 stated that snacks are not brought to residents in the evening, that snacks are left at the nurse's station and stated that residents can come get them. However, the other Residents in attendance (Residents 22, 29, and 8) were unaware that snacks were left at the nurses' station and further stated that if they were in bed already, they would not be able to go to the nurses' station without assistance and were unaware they could ask staff for a snack in the evening. The facility was unable to provide documented evidence that efforts had been made to resolve resident complaints concerning call bell timeliness as of the survey ending September 4, 2025, that had been brought up during resident council meeting. During an interview on September 4, 2025, at 9:10 a.m., the Nursing Home Administrator (NHA) confirmed the absence of documented actions addressing grievances raised during Resident Council meetings or Residents Affected - Some Page 1 of 6 395092 395092 09/04/2025 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0565 verbal complaints. 28 Pa. Code 201.18 (e)(1)(4) Management. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code 211.10 (d) Resident care policies. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395092 Page 2 of 6 395092 09/04/2025 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on a review of the facility's abuse prohibition policy, employee personnel files and staff interviews, it was determined the facility failed to implement procedures to fully screen five employees out of five to ensure they were eligible for employment in a long term care nursing care facility. (Employees 1, 2, 3, 4, and 5).Findings include: A review of the facility's Resident Abuse policy last reviewed by the facility July 29, 2025, revealed the requirement for screening potential employees included obtaining references from the most recent or previous employer. Review of employee personnel files revealed the following: Employee 1 (Nurse Aide): Hired on June 3, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer to fully screen the individual to ensure the individual was eligible for employment in a long term care nursing facility. Employee 2 (Registered Nurse): Hired on August 11, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer. Employee 3 (Activities Aide): Hired on May 5, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer. Employee 4 (Licensed Practical Nurse): Hired on July 31, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the employees' most recent former employer. Employee 5 (Housekeeping): Hired on May 15, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer. Interview with the Nursing Home Administrator (NHA) on September 4, 2025, at 10:15 a.m. the NHA verified there was no evidence that previous employers were contacted for information regarding the employees past work history. The facility failed to follow its own abuse prohibition policy by not verifying previous employment for two out of five new hires. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a)(c) Resident Rights. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.19 (1) Personnel records. Residents Affected - Some 395092 Page 3 of 6 395092 09/04/2025 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 16 residents reviewed (Resident 9).Findings include: A review of Resident 9's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event). The resident's current care plan, in effect at the time of review on September 4, 2025, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. The facility failed to develop and implement an individualized person-centered plan to address, this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety. Interview with the Nursing Home Administrator on September 4, 2025, at 10:00 a.m., confirmed the facility was unable to demonstrate the facility provided culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. 28 Pa Code 211.12 (d)(3)(5) Nursing services. Residents Affected - Few 395092 Page 4 of 6 395092 09/04/2025 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications in one of two medication carts observed (East Hall).Findings include: Review of the facility policy titled Administering Medication last reviewed by the facility July 29,2025, indicated that multi-use vials that have been opened or accessed (e.g. needle punctured) are to be dated at the time of first use, and the expiration or beyond-use date is to be indicated on the medication label to ensure the product remains safe and effective. Dating a multi-use medication at the time of first use is essential because staff must be able to determine when the medication has reached its beyond-use date (the last date it can safely be used once opened). An observation of the medication cart located on East Hall unit on September 3, 2025, at 8:45 AM, in the presence of Employee 4 (Licensed Practical Nurse ) of the medication stored in the medication cart, revealed one (1) multi-dose insulin pen of Insulin Glargine (a long acting insulin medication used to lower blood sugar) that had been opened and available for resident use, but not dated when initially opened. An interview with Employee 4 (LPN) on September 3,2025, at 8:45 AM confirmed the multi dose insulin pen of Insulin Glargine was opened, and available for resident use, but not dated when initially opened. An interview was conducted with the Nursing Home Administrator (NHA) on September 3, 2025, at 1:30 PM to review the above findings related to the facility's failure to adhere to acceptable storage and labeling practice for multi-dose medications. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services 395092 Page 5 of 6 395092 09/04/2025 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department. Findings included:Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). The initial tour of the dietary department conducted and confirmed with the facility's Certified Dietary Manager (CDM) on September 2, 2025, at 10:15 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified: Upon entering the facility's refrigerated and freezer storage room, it was observed that the steel exterior door had an eroded and worn area,1.5 inches in size, at the lower right corner, creating an opening to the outdoors. Inside the storage room, along the shelving that held cases of bread products and 50-pound bags of potatoes and onions, debris was present around the perimeter and corners of the room, including crumbled leaves and small deceased insects. Upon exiting the storage room, observed the exterior door failed to properly latch to securely close the door. An interview with the CDM confirmed the above observations and reported the exterior door had been not functioning properly for a while and reported it to the maintenance department verbally and through TELs (is a computerized maintenance management platform that helps organizations manage preventative maintenance, work orders, and asset tracking).An interview with Employee 6, the facility's maintenance manager, on August 4, 2025, at 10:47 AM, confirmed that he had been made aware of the dietary storage room's broken exterior door of the storage room, but didn't repair it. Interview with the Nursing Home Administrator (NHA) on August 4, 2025, at 10:30 AM, confirmed all areas of food storage in the dietary department was to be maintained to ensure food safety.28 Pa. Code 201.18 (e) (2.1) Management. 28 Pa. Code 211.6 (f) Dietary Services. 395092 Page 6 of 6