Health inspection·March 7, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for two of 41 residents reviewed (Residents 88, 115). Findings include: The facility's abuse policy, dated October 6, 2023, indicated that each resident had the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and exploitation. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 88, dated January 9, 2024, indicated that the resident was cognitively intact and required assistance from staff for all his care needs. Resident 88's care plan, dated December 21, 2023, indicated that the resident was dependent on staff for all activities of daily living. Facility documents, undated, revealed that Nurse Aide 1 completed the nurse aide training program on December 22, 2023, and that he received education on abuse, resident rights, and resident psychosocial needs in the nurse aide class. Facility investigation documents, dated February 2, 2024, revealed that Resident 88 reported that Nurse Aide 1 removed his call bell from his reach and told him to stop ringing so much. A written statement from Nurse Aide 2, dated February 2, 2024, revealed that Nurse Aide 1 told her that Resident 88 rang his bell too much and that he told the resident he was not the only resident that needed care and that he removed his call bell from his reach. A written statement from Licensed Practical Nurse 3, dated February 2, 2024, revealed that Nurse Aide 1 was complaining about Resident 88 ringing his call bell too much and that she asked Nurse Aide 2 to care for the resident instead. A review of Nurse Aide 1's time card revealed that he worked a double shift from 3:00 p.m. on Feburary 1, 2024, until 7:00 a.m. on February 2, 2024 and that he was not immediately removed from his shift when Nurse Aide 2 and Licensed Practical Nurse 3 were made aware that he removed the call bell from Resident 88 and told him not to ring any more for the night shift. Interview with Resident 88 on March 7, 2024, at 4:00 p.m. revealed that he used his call bell for Page 1 of 23 395830 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0600 care because he is totally dependent on staff for all of his care needs. Level of Harm - Minimal harm or potential for actual harm Interview with the the Nursing Home Administrator and the Director of Nursing on March 7, 2024, at 4:00 p.m. confirmed that Nurse Aide 1 should never have removed Resident 88's call bell from his reach and told him not to ring his call bell for assistance. The Nursing Home Administrator stated that Nurse Aide 1 should have been removed from duty when staff were made aware that he removed the call bell from Resident 88 and told the resident not to ring anymore that night; however, the licensed practical nurse did not report the allegation of abuse against Nurse Aide 1 immediately to her supervisor as she should have done. Residents Affected - Few A comprehensive MDS for Resident 115, dated November 29, 2023, indicated that the resident was cognitively intact and required assistance from staff for all his care needs. Resident 115's care plan, dated November 24, 2023, indicated that the resident was dependent on staff for all activities of daily living. Facility documents, undated, revealed that Nurse Aide 4 completed the nurse aide education class on October 27, 2023, and that she received education on abuse, resident rights, and resident psychosocial needs in the class. Facility investigation documents, dated January 22, 2024, revealed that Resident 115 reported that Nurse Aide 4 withheld Resident 115's urinal from him and told him to urinate on himself, made fun of him for having lit himself on fire, and told him he needed tough love, causing Resident 115 to urinate on the floor. A written statement from Nurse Aide 5, dated January 21, 2024, revealed that Nurse Aide 4 stated she was not going to deliver the lunch tray to or feed Resident 115 because she told him she was not going to hold his f*cking urinal, that he could call his mother to hold it for him. A written statement from Social Services Director, dated January 22, 2024, revealed that Resident 115 asked Nurse Aide 4 for his urinal and that she refused to get it for him and she told him he could urinate on himself. Resident 115 stated that Nurse Aide 4 told him that he was incontinent just to get her into trouble. A review of Nurse Aide 4's time card revealed that she worked the entire shift on January 21, 2024, and that she was not removed from duty when staff were made aware of Resident 115's allegations that she had refused to provide care for him and insulted him. Interview with the Nursing Home Administrator and the Director of Nursing on March 7, 2024, at 4:00 p.m. confirmed that Nurse Aide 4 should not have refused to care for Resident 115. The Nursing Home Administrator stated that she should have been removed from duty when staff were made aware of the allegations at lunch time; however, the Director of Nursing had not arrived at the building until the end of Nurse Aide 4's shift and therefore she was not immediately removed from care. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(a)(j) Resident Rights. 395830 Page 2 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0600 28 Pa. Code 211.12(d)(5) Nursing Services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395830 Page 3 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow its abuse policy regarding the immediate release of an involved staff member from their duty pending a full investigation, to protect the resident/victim for two of 41 residents reviewed (Residents 88, 115) and to implement its abuse prohibition policies regarding verifying new employees' standing with the Pennsylvania Nurse Aide Registry or the State Board of Nursing for two of five new employees reviewed (Nurse Aide 11, Registered Nurse 12). Residents Affected - Few Findings include: The facility's policy regarding abuse, dated October 6, 2023, indicated that every complaint or allegation of resident abuse or neglect shall be promptly reported to the immediate supervisor of the area, and the Nursing Home Administrator and/or his/her designee. Each report shall be treated promptly and with discretion, with the following priorities of concern: protection of the person and rights of the resident (alleged victim); compliance with pertinent laws and regulations; protection of the rights of the alleged abuser, whether employee, contractor, volunteer, visitor, another resident or other individual; maintenance of order and smooth operation of the facility. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 88, dated January 9, 2024, indicated that the resident was cognitively intact and required assistance from staff for all his care needs. Resident 88's care plan, dated December 21, 2023, indicated that the resident was dependent on staff for all activities of daily living. Facility investigation documents, dated February 2, 2024, revealed that Resident 88 reported that Nurse Aide 1 removed his call bell from his reach and told him to stop ringing so much. A written statement from Nurse Aide 2, dated February 2, 2024, revealed that Nurse Aide 1 told her that Resident 88 rang his bell too much and that he told the resident he was not the only resident that needed care and that he removed his call bell from his reach. A written statement from Licensed Practical Nurse 3, dated February 2, 2024, revealed that Nurse Aide 1 was complaining about Resident 88 ringing his call bell too much and that she asked Nurse Aide 2 to care for the resident instead. A review of Nurse Aide 1's time card revealed that he worked a double shift from 3:00 p.m. on Feburary 1, 2024, until 7:00 a.m. on February 2, 2024, and that he was not immediately removed from his shift when Nurse Aide 2 and Licensed Practical Nurse 3 were made aware that Nurse Aide 1 removed the call bell from Resident 88 and told him not to ring any more for the night shift. Interview with Resident 88 on March 7, 2024, at 4:00 p.m. revealed that he used his call bell for care because he is totally dependent on staff for all of his care needs. Interview with the Nursing Home Administrator and the Director of Nursing on March 7, 2024, at 4:00 p.m. confirmed that Nurse Aide 1 was not immediately removed from his duty the night of the allegation and that he should have been. A comprehensive MDS for Resident 115, dated November 29, 2023, indicated that the resident was 395830 Page 4 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cognitively intact and required assistance from staff for all his care needs. Resident 115's care plan, dated November 24, 2023, indicated that the resident was dependent on staff for all activities of daily living. Facility documents, undated, revealed that Nurse Aide 4 completed the nurse aide education class on October 27, 2023, and that she received education on abuse, resident rights, and resident psychosocial needs in the class. Facility investigation documents, dated January 22, 2024, revealed that Resident 115 reported that Nurse Aide 4 withheld the use of Resident 115's urinal from him, that she told him to urinate himself, made fun of him for having lit himself on fire, and told him he needed tough love, causing Resident 115 to urinate on the floor. A written statement from Nurse Aide 5, dated January 21, 2024, revealed that Nurse Aide 4 stated she was not going to deliver the lunch tray to or feed Resident 115 because she told him she was not going to hold his f*cking urinal, that he could call his mother to hold it for him. A written statement from Social Services Director, dated January 22, 2024, revealed that Resident 115 asked Nurse Aide 4 for his urinal and that she refused to get it for him and she told him he could urinate himself. Resident 115 stated that Nurse Aide 4 told him that he was incontinent just to get her into trouble. A review of Nurse Aide 4's time card revealed that she worked the entire shift on January 21, 2024, and that she was not removed from duty when staff were made aware of Resident 115's allegations that she had refused to provide care for him and insulted him. Interview with the Nursing Home Administrator and the Director of Nursing on March 7, 2024, at 4:00 p.m. confirmed that Nurse Aide 4 should not have refused to care for Resident 115. The Nursing Home Administrator stated that she should have been removed from duty when staff were made aware of the allegations at lunch time; however, the Director of Nursing had not arrived at the building until the end of Nurse Aide 4's shift and therefore she was not removed from care immediately. The facility's policy regarding abuse prohibition, dated October 6, 2023, indicated that the facility would check the nurse aide registry for enrollment and state licensure agency for verification prior to employment. The personnel file for Nurse Aide 11 revealed that she was hired on November 7, 2023; however, her enrollment on the Pennsylvania Nurse Aide Registry was not verified until March 5, 2024, which was 119 days after being hired. The personnel file for Registered Nurse 12 revealed that she was hired on January 3, 2024; however, there was no documented evidence that her professional license was verified with the State Board of Nursing until March 5, 2024, which was 62 days after being hired. Interview with the Human Resources Director on March 6, 2024, at 2:30 p.m. confirmed that there was no documented evidence that Nurse Aide 11's enrollment in the nurse aide registry and Registered Nurse 12's licensure were verified prior to employment. 28 Pa. Code 201.18(e)(1) Management. 395830 Page 5 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for seven of 41 residents reviewed (Residents 1, 49, 68, 87, 90, 122, 124). Residents Affected - Some Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that if the pneumococcal (pneumonia) vaccine was not received, Section O0300C (pneumococcal vaccine) was to be coded with the reason the pneumonia vaccine was not received. The section was to be coded with a one (1) if the resident was not eligible (medical contraindication); two (2) if the vaccine was offered and declined; or (3) if the vaccine was not offered. A quarterly MDS assessment for Resident 1, dated January 5, 2024 revealed that Section O0300B was coded with not assessed, no information. However, a pneumococcal consent/declination form, dated June 30, 2023, revealed that Resident 1 was offered the pneumococcal vaccine and declined. An admission MDS assessment for Resident 49, dated February 19, 2024, revealed that Section O0300B was coded with not assessed, no information. However, an immunization form for Resident 49, dated February 12, 2024, revealed that the resident was offered and refused the flu and pneumococcal vaccine. An annual MDS assessment for Resident 68, dated December 28, 2023, revealed that Section 00300B was coded with not assessed, no information. However, an immunization form for Resident 68, dated January 5, 2023, revealed that the resident was offered and refused the flu and pneumococcal vaccine. A quarterly MDS assessment for Resident 87, dated March 6, 2024, revealed that Section O0250C was coded with not assessed, no information; and Section O0300B was coded with not assessed, no information. An immunization form for Resident 87, dated December 8, 2023, revealed that the resident was offered and refused the flu and pneumococcal vaccine. A quarterly MDS assessment for Resident 90, dated February 16, 2024, revealed that Section O0300B was coded with not assessed, no information. An immunization form, undated, revealed that Resident 90 received a pneumococcal vaccine on July 18, 2019, and August 10, 2020. An admission MDS assessment for Resident 122, dated January 25, 2024, revealed that Section O0300B was coded with not assessed, no information. However, an immunization form, dated January 18, 2023, revealed that Resident 122 was offered the pneumococcal vaccine and flu vaccine and declined. An admission MDS assessment for Resident 124, dated February 25, 2024, revealed that Section O0300B was coded with not assessed, no information. However, an immunization form for Resident 124, dated February 17, 2024, revealed that the resident was offered and refused the flu vaccine. Interview with Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on March 7, 2024, at 12:14 p.m. confirmed that all of the MDS assessments listed above were not coded correctly because the vaccine information was not a part 395830 Page 6 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0641 of the electronic medical record and was located in their paper charts. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.5(f) Clinical Records. Residents Affected - Some 395830 Page 7 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on clinical record reviews and staff interviews, it was determined that the facility failed to revise resident care plans with individualized interventions to address their care needs for one of 41 residents reviewed (Resident 49). Findings include: A facility policy for pacemakers (a small, battery-powered device that prevents the heart from beating too slowly), dated October 6, 2023, revealed that the facility will place the physician's orders for pacemaker monitoring on the resident's care plan. An admissions Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 49, dated February 19, 2024, revealed that the resident was understood and could understand others, was cognitively intact, required maximum assistance with dressing and toilet use, and had diagnoses of coronary artery disease and heart failure. The current care plan for Resident 49 revealed that he had a pacemaker; however, there was no documented evidence of an appointment for pacemaker monitoring. Interview with the Registered Nurse Assessment Coordinator (a nurse who monitors and evaluates resident care to ensure the appropriate execution of prescribed care plans) on March 7, 2024, at 9:05 a.m. confirmed that the care plan should have been updated to reflect resident-specific information for his pacemaker. 28 Pa. Code 201.24(e)(4) admission Policy. 28 Pa. Code 211.12(d)(5) Nursing services. 395830 Page 8 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify physician's orders for pain management for one of 41 residents reviewed (Resident 19). Residents Affected - Some Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. Physician's orders for Resident 19, dated January 17, 2024, included an order for the resident to receive one 10-325 milligrams (mg) tablet of Norco (a narcotic pain medication) every six hours for moderate to severe pain (4-10) (on a scale of 0 to 10 where 10 is the worst pain). The order did not include instructions for the staff to give the Norco when the resident's pain rating was 0 to 3, and there was no documented evidence that the nursing staff attempted to clarify the orders with the resident's physician. Resident 19's Medication Administration Records (MAR's) for February and March 2024 revealed the following: Staff administered one 10-325 mg tablet of Norco for a pain rating of 0 at 12:00 a.m. on February 1, 2, 4, 5, 7, 9, 12, 13, 15, 17, 18, 20, 23-26, and March 2, 2024. Staff administered one 10-325 mg tablet of Norco for a pain rating of 0 at 6:00 a.m. on February 1-5, 7, 8, 12-15, 17, 19, 23, 25, and 26, and March 1, 2, and 5, 2024. Staff administered one 10-325 mg tablet of Norco for a pain rating of 0 at 12:00 p.m. on February 1-21, 23, and 25-29, and March 1, 2, 4-6, 2024. Staff administered one 10-325 mg tablet of Norco for a pain rating of 0 at 6:00 p.m. on February 1-6, 9-20, 22, 24, 25, and 27-29, and March 1, 2, 4, and 5, 2024. Staff administered one 10-325 mg tablet of Norco for a pain rating of 2 at 6:00 a.m. on February 6, 16, and 21, 2024. Staff administered one 10-325 mg tablet of Norco for a pain rating of 2 at 6:00 p.m. on February 23, 2024. Staff administered one 10-325 mg tablet of Norco for a pain rating of 3 at 6:00 a.m. on March 6, 2024. An interview with the Registered Nurse/Staff Development/Nurse Aide Educator on March 7, 2024, at 8:53 a.m. confirmed that Resident 19's physician's orders for pain medications should have been clarified with the physician. 395830 Page 9 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0658 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395830 Page 10 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide medications as ordered by the physician for one of 41 residents reviewed (Resident 107). Residents Affected - Few Findings include: Physician's orders for Resident 107, dated December 14, 2023, included an order for the resident to receive 10 milligrams (mg) of Oxycodone HCL every six hours as needed for pain. However, the resident's Medication Administration Record (MAR) for January 2024 revealed that the resident was administered 5 mg Oxycodone on January 17 and January 20, 2024, and not the 10 mg that was ordered. Interview with Registered Nurse 6 on March 7, 2024, at 2:43 p.m. confirmed that Resident 107 only received 5 mg of Oxycodone on January 17 and 20, 2024, and not the 10 mg he was ordered. 28 Pa. Code 211.12(d)(5) Nursing Services. 395830 Page 11 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that fall prevention interventions were in place as ordered and care planned for one of 41 residents reviewed (Resident 19). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated December 5, 2023, revealed that the resident was understood, could understand, had a diagnosis which included a cerebral vascular accident (CVA - commonly known as a stroke), and had two or more falls with no injuries since his admission to the facility. A care plan for the resident, dated December 5, 2023, revealed that the resident was at risk for falls and that the resident was to have bilateral fall mats. Physician's orders for Resident 19, dated November 28, 2023, included an order for the resident to have bilateral fall mats. Nursing notes for Resident 19, dated December 4, 2023, and January 1, 2, 6, 7, and 8, 2024, revealed that staff entered the resident's room and found the resident out of bed on the fall mat. Observations of Resident 19 on March 4, 2024, at 11:03 a.m., 12:02 p.m., and 12:06 p.m. revealed that the resident was lying in bed and a fall mat was placed on the floor on the right side of the bed toward the window. There was no fall mat on the floor on the left side of the resident's bed toward the door. Interview with Agency Nurse Aide 7 on March 4, 2024, at 12:06 p.m. confirmed that Resident 19's fall mat was placed on the right side of the resident's bed toward the wall and not on the left side toward the door. 28 Pa. Code 211.12(d)(5) Nursing Services. 395830 Page 12 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a tube feeding was administered in accordance with the facility's policy for one of 41 residents reviewed (Resident 122). Findings include: The facility's policy regarding enteral feeding (nutritional formula provided via a tube inserted into the stomach), dated October 6, 2023, indicated that nursing staff will check and document for residual volume prior to administering the feeding. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 122, dated January 25, 2024, indicated that the resident was cognitively intact, required minimal assistance from staff for all daily care needs, and had a feeding tube (a tube surgically implanted into the stomach for feeding). Review of Resident 122's clinical record from January 18, 2024, through March 4, 2024, revealed that there was no documented evidence that gastric residuals were checked prior to administering tube feedings per policy. Interview with the Registered Dietician on March 6, 2024, at 10:32 a.m. confirmed that there was no documented evidence that gastric residuals were checked prior to tube feedings for Resident 122 and should have been per the facility's policy. 28 Pa. Code 211.12(d)(5) Nursing Services. 395830 Page 13 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observations and clinical record reviews, as well as staff interviews, it was determined that the facility failed to complete a safety assessment for one of 41 residents reviewed (Resident 49) who used top side rails for mobility. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 49, dated February 19, 2024, revealed that the resident was understood and could understand, and had a diagnosis of arthritis (inflammation or swelling of one or more joints). Observations of Resident 49 lying in his bed on March 6, 2024, at 10:06 a.m. revealed that the bed had bilateral top side rails. A review of Resident 49's clinical record revealed no documented evidence that a side rail safety assessment had been conducted prior to the use of bilateral top side rails for mobility purposes. An interview with Nursing Home Administrator on March 7, 2024, at 11:04 a.m. confirmed that a side rail safety assessment was not completed for Resident 49 and should have been. 28 Pa. Code 211.12(d)(5) Nursing Services. 395830 Page 14 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of anti-anxiety medications for one of 41 residents reviewed (Resident 79). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 79, dated December 27, 2023, indicated that the resident was cognitively impaired, received antianxiety medication, and had diagnoses that included dementia. Physician's orders, dated December 17, 2023, included an order for the resident to receive 0.5 milligrams/milliliter (mg/mL) of lorazepam (an antianxiety medication) gel applied to the inner wrist topically every eight hours as needed for anxiety, and physician's orders, dated January 18, 2024, included orders for the resident to receive 0.5 mg of Ativan (an antianxiety medication) every eight hours as needed for anxiety. Physician's orders, dated February 1, 2024, included orders for the resident to receive 1 mg/mL of lorazepam gel applied to the inner wrist topically every 12 hours as needed for anxiety/agitation, and physician's orders, dated February 14, 2024, included orders for the resident to receive 1 mg/mL of lorazepam gel applied to the inner wrist topically every six hours as needed for anxiety/agitation. Resident 79's Medication Administration Records (MAR's) for December 2023 and January, February, and March 2024, revealed that staff administered as needed Ativan to the resident on December 25 at 6:35 p.m., December 27 at 12:39 p.m., January 23 at 6:03 p.m., January 24 at 4:38 p.m., and January 28 at 2:12 p.m., February 6 at 9:39 a.m., February 8 at 5:10 p.m., February 14 at 11:37 a.m., February 17 at 12:29 a.m. and 7:58 p.m., and February 24 at 11:18 a.m. There was no documented evidence in Resident 79's clinical record regarding any non-medication interventions that were attempted prior to the administration of Ativan on the above days. Interview with Licensed Practical Nurse 8 on March 7, 2024, at 1:07 p.m. confirmed that non-medication interventions were to be attempted prior to medicating residents and the interventions were to be documented. Interview with the Nursing Home Administrator on March 7, 2024, at 1:38 p.m. confirmed that there was no documentation of any non-medication interventions prior to the administration of Ativan. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 395830 Page 15 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

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 clinical record reviews, review of pharmacy labels for medications, and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled for one of 41 residents reviewed (Resident 107). Findings include: Physician's orders for Resident 107, dated December 14, 2023, included an order for the resident to receive 10 milligrams (mg) of Oxycodone HCL (narcotic pain medication) every six hours as needed for pain. Review of the label on Resident 107's pill card of Oxycodone revealed that the card contained 5 mg tablets and the resident was to receive only one tablet every six hours as needed for pain. Interview with Registered Nurse 6 on March 7, 2024, at 2:43 p.m. confirmed that Resident 107's current physician's order for Oxycodone did not match the label on the card of Oxycodone and it should have. 28 Pa. Code 211.9(h) Pharmacy Services. 395830 Page 16 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Residents Affected - Some Findings include: The facility's current policy regarding food temperatures and resident tray audits, dated October 6, 2023, indicated that the facility's standards for test tray temperatures were to be 135 degrees Fahrenheit (F) or higher for soups, hot cereals, eggs, pancakes/waffles/French toast, entree/casseroles, starches, and vegetables; 120 to 160 degrees F for hot beverages; and 41 degrees F and lower for salads, desserts, fruit, juice, and milk. Interview with Resident 12 on March 4, 2024, at 12:51 p.m. revealed that he does not like the taste of the food. Interview with Resident 45 on March 4, 2024, at 11:45 a.m. revealed that the French fries she receives are cold, and that she threw up when she had the liver and onions. Observations in the main kitchen on March 6, 2024, revealed that the Second Floor second cart left the main kitchen at 11:39 a.m. and arrived on the Second Floor at 11:40 a.m. Trays were passed to the residents in their rooms at 11:44 a.m. and the last resident was served at 12:11 p.m. At 12:12 p.m. the temperature of the pork and gravy was 119.3 degrees F, the temperature of the rice pilaf was 127.6 degrees F, the temperature of the steamed broccoli was 117.1 degrees F, the temperature of the cinnamon scalloped peaches was 51 degrees F, the temperature of the coffee was 136.7 degrees F, and the temperature of the milk was 44.6 degrees F. The pork and gravy, rice pilaf, and steamed broccoli were lukewarm and not appetizing. Interview with the Registered Dietitian at the time of observation revealed that they would like their hot foods to be at a minimum of 135 degrees F. 28 Pa. Code 211.6(b) Dietary Services. 395830 Page 17 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

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 review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to ensure that food was served under sanitary conditions, and failing to ensure that ice was made and stored in sanitary ice machines for one of four ice machines (Second Floor Nourishment Station). Findings include: Observations in the walk-in freezer on March 4, 2024, at 9:09 a.m. and March 6, 2024, at 11:05 a.m. revealed that there was an accumulation of ice on the ceiling, the floor, and metal storage racks, as well as on cases of asparagus cuts and tips, fresh frozen brussel sprouts, and breaded popcorn shrimp that were stored on the shelves below the freezer condenser. Interview with the Registered Dietitian on March 6, 2024, at 11:05 a.m. confirmed that there was an accumulation of ice on the food products stored below the freezer condensers in the walk-in freezer. Review of the main kitchen's daily floor cleaning assignments, undated, revealed that the floors must be swept and mopped daily. Observations in the main kitchen on March 4, 2024, at 9:15 a.m. and March 6, 2024, at 11:07 a.m. revealed that there was a French fry along with other food debris under a wheeled cart sitting beside the prep table across from the two door ovens. Interview with the Registered Dietitian on March 6, 2024, at 11:26 a.m. confirmed that there was a French fry along with other food debris under a wheeled cart sitting beside the prep table across from the two door ovens. The facility's current policy regarding handwashing, dated October 6, 2023, revealed that food handlers will wash their hands before they start work and after touching anything else that may contaminate hands, such as unsanitized equipment, work surfaces, or wash cloths. Observations during the lunch meal on March 6, 2024, at 11:16 a.m., 11:20 a.m., 11:25 a.m. and 11:32 a.m. revealed that Dietary Worker 9 was at the end of the tray line receiving the trays with the prepared plates. Dietary Worker 9 added the prepared cinnamon scalloped peaches, as well as a roll and jelly, to the tray and then placed them into the cart to be delivered to the residents. When the cart was full, Dietary Worker 9 left the kitchen with the cart to deliver it to the nursing units. Upon return to the main kitchen, Dietary Worker 9 did not perform hand washing, and she continued to take the prepared trays with the prepared plates, place the prepared cinnamon scalloped peaches, as well as a roll and jelly, to the tray and placed them into the carts for delivery. Interview with the Registered Dietitian on March 6, 2024, at 11:26 a.m. confirmed that Dietary Worker 9 should have performed hand washing each time she returned to the kitchen from the nursing units. Observations of the Hoshizaki ice machine in the Second Floor Nourishment Station on March 7, 2024, 395830 Page 18 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some at 9:42 a.m. revealed that the end of the drain line coming from the ice machine had a buildup of a black, removable substance. Interview with the Director of Maintenance on March 7, 2024, at 10:25 a.m. confirmed that the ice machine in the Second Floor Nourishment Station had a buildup of a black, removable substance on the end of the drain line coming from the ice machine. He indicated that the ice machines are cleaned quarterly. 28 Pa. Code 211.6(f) Dietary Services. 28 Pa. Code 207.4 Ice Containers and Storage. 395830 Page 19 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) surveys ending April 13, 2023, and July 27, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending March 7, 2024, identified repeated deficiencies related to freedom from abuse/neglect, accuracy of Minimum Data Sets (MDS) assessments, services provided to meet professional standards, quality of care, safety and accidents hazards, palatability of food, food procurement/storage/preparation, and infection control. The facility's plan of correction for a deficiency regarding freedom from abuse/neglect, cited during the survey ending July 27, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F600, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding freedom from abuse/neglect. The facility's plan of correction for a deficiency regarding completing accurate MDS assessments, cited during the survey ending April 13, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accurate MDS assessments. The facility's plan of correction for a deficiency regarding services provided to meet professional standards, cited during the survey ending April 13, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F658, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding services provided to meet professional standards. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending April 13, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care. The facility's plan of correction for a deficiency regarding safety and accident hazards, cited during the surveys ending April 13, 2023, and July 27, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding safety and accident 395830 Page 20 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0867 hazards. Level of Harm - Minimal harm or potential for actual harm The facility's plan of correction for a deficiency regarding palatable food, cited during the survey ending April 13, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F804, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding palatable food. Residents Affected - Some The facility's plan of correction for a deficiency regarding food procurement/storage/preparation, cited during the survey ending April 13, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding food procurement/storage/preparation. The facility's plan of correction for a deficiency regarding infection control, cited during the survey ending April 13, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding infection control. Refer to F600, F641, F658, F684, F689, F804, F812, F880. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 395830 Page 21 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of guidance from the Pennsylvania Department of Health (DOH) and review of the facility's policies, as well as observations and staff interviews, it was determined that the facility failed to follow infection control standards and DOH guidelines to reduce the spread of infections and prevent cross-contamination. Residents Affected - Some Findings include: Pennsylvania Department of Health, COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care (LTC), dated February 2024, revealed that personal protective equipment (PPE) is a key component of infection prevention practices in LTCF's. PPE is equipment that is worn to minimize exposure to hazards that may cause workplace harm or illness. In LTCF's and other medical settings, health care professionals (HCP) are to wear PPE to protect them from potentially infectious conditions. This includes equipment such as respirators, masks, gowns, gloves, and eye protection. While having the recommended PPE is important to protect the wearer, it is equally critical to ensure the wearer knows how to appropriately don (put on) and doff (take off) PPE to best protect themselves from infectious disease exposure. Source control refers to the use of respirators or well-fitting facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. People, particularly those at high risk for severe illness, should wear the most protective form of source control that they are able to wear. The facility's current policy regarding Infection Control COVID-19 General Guidelines, dated October 6, 2023, revealed that the core principles of COVID-19 infection prevention is source control used by staff and visitors (defined as well-fitting face covering or mask covering mouth and nose). When the community transmission is high, everyone entering the facility must have a source control mask in place and utilize it at all times. Appropriate staff use of PPE. Physician's orders for Resident 45, dated March 5, 2024, included an order for the resident to be in contact isolation (steps that healthcare facility visitors and staff need to follow before going into a resident's room). A nursing note for Resident 45, dated March 5, 2024, revealed that the resident's husband was at the bedside and reported that when the resident called him last night, she seemed confused. There was no confusion today. She was alert to her baseline. Her voice was hoarse. She was tested for COVID-19 and the result was positive. Observations on March 6, 2024, at 12:00 p.m. revealed that there was sign on Resident 45's doorway indicating PPE usage in red zone COVID-19 Positive or COVID-19 symptoms with test pending. Contact and Droplet Precautions. PPE required at all times. N95 respirator, goggles/face shield. PPE required during patient care: gloves, N95 respirator, goggles/face shield, gown. Observations revealed that there was a cart sitting outside the resident's room with personal belongings on the cart. The Registered Nurse/Staff Development/Nurse Aide Educator was inside the room, opened the door wearing a surgical mask, a gown, and had an N95 mask on under her chin. She obtained items from the cart and took them into the room closing the door behind her. She opened the door and obtained more items from the cart, closing the door several times during the observation. Interview with the Registered Nurse/Staff Development/Nurse Aide Educator on March 6, 2024, at 12:21 p.m. confirmed that she should have been wearing a N95 mask while in Resident 45's room. 395830 Page 22 of 23 395830 03/07/2024 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with the Nursing Home Administrator on March 6, 2024, at 3:00 p.m. confirmed that the Registered Nurse/Staff Development/Nurse Aide Educator should have been wearing a N95 mask while in Resident 45's room. Observations of Agency Licensed Practical Nurse 10 on March 7, 2024, at 12:40 p.m. revealed that she was down the Second Floor B Hallway with the medication cart that had several COVID-19 positive rooms with her surgical mask on down under her chin. She returned the medication cart to the medication room and shortly after came out of the medication room with the medication cart with her surgical mask down under her chin. She proceeded down the Second Floor Hallway B and stopped outside a resident's room. Interview with Agency Licensed Practical Nurse 10 on March 7, 2024, at 12:52 p.m. revealed that this was her first time working at the facility and she was not sure of the facility's requirements. Interview with the Nursing Home Administrator on March 7, 2024, at 1:42 p.m. confirmed Agency Licensed Practical Nurse 10 should have been wearing a surgical mask. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395830 Page 23 of 23