Health inspection·February 11, 2026

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility policy, facility-provided documentation, and staff interviews, it was determined the facility failed to ensure timely, comprehensive assessment and monitoring of wounds and failed to ensure implementation of necessary practices to prevent worsening skin breakdown for 1 of 7 residents reviewed (Resident 1).Findings include:According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the best pressure ulcer practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of a facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol revealed the nursing staff will assess and document an individual's significant risk factors for developing pressure sores. In addition, the nurse shall assess and document and report vital signs, a full assessment of the pressure sore including location, stage (the classification of a pressure injury based on the depth and extent of tissue damage), length, width, depth, and presence of exudates(fluid) or necrotic tissue (dead tissue). A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], 2025, with diagnoses to include dementia (decline in mental ability such as memory, reasoning, and communication severe enough to interfere with daily life), and peripheral vascular disease (blood circulation disorder causing narrowed, blocked, or spasming vessels arteries or veins outside the heart and brain and increases risk for wounds). A review of the resident's Annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 10, 2025, revealed the resident was cognitively intact as evidence by a BIMS score of 09 (Brief Interview for Mental Status is a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 08-12 indicates moderately impairment). Additionally, this MDS indicated Resident 1 used a wheelchair for mobility, required substantial/maximal assistance with upper dressing and personal hygiene, lower body dressing, bed mobility, and toileting. A review of Resident 1's clinical record revealed an ongoing skin integrity issue related to vascular wounds of bilateral lower extremities. A review of Resident 1's progress notes revealed the following documentation:October 30, 2025, at 8:26 AM: Left lower extremity Residents Affected - Few (continued on next page) 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 Page 1 of 2 Event ID: 395587 Printed: 05/15/2026 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 395587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows Nursing and Rehabilitation Center 4 East Center Street Dallas, PA 18612 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)