Health inspection·November 21, 2025

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on review of clinical records and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for eight of eight residents reviewed (Residents R9, R24, R25, R26, R28, R31, R35 and R37). Findings include: No facility policy was provided that included a written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/resident representative can understand, including a summary of the resident's medications and dietary instructions, any services and treatments to be administered. Resident R9's clinical record revealed an admission date of 10/23/25, with diagnoses including, aftercare from spinal surgery, high blood pressure, cervical myelopathy (compression of the spinal cord in the neck that can cause balance problems, weakness, and loss of fine motor skills), and osteoarthritis (a type of joint disease that results of breakdown of cartilage and bone). Resident R24's clinical record revealed an admission date of 11/13/25, with diagnoses including ortho aftercare from fractured right femur nailing (surgical procedure to stabilize a fractured or weakened femur, thigh bone in upper leg connecting to hip), morbid obesity (a person who is severely overweight), diabetes mellitus (a chronic condition where the body doesn't produce enough insulin or can't use the insulin effectively leading to high blood sugar levels), and high blood pressure. Resident R25's clinical record revealed an admission date of 11/17/25, with diagnoses including infection of sacral stage four decubitus (infection of a severe pressure injury to sacrum, the large triangular bone at base of spine, that extends into muscle, tendon, or bone), diabetes mellitus, hypothyroidism (a condition when the thyroid gland doesn't make enough thyroid hormone to meet the body's needs), chronic obstructive pulmonary disease (COPD - a group of respiratory conditions that involve shortness of breath, a persistent cough, and excess mucus). Resident R26's clinical record revealed an admission date of 11/04/25, with diagnoses including ortho aftercare status post repair of fractured distal fibula, anxiety, hyperlipidemia (high levels of fat, including cholesterol and triglycerides, in the blood) and high blood pressure. Resident R28's clinical record revealed an admission date of 11/10/25, with diagnoses including ortho aftercare from a right total hip repair, atrial fibrillation (abnormal heart rythm), hyperlipidemia (high levels of fat, including cholesterol and triglycerides, in the blood) and high blood pressure. Resident R31's clinical record revealed an admission date of 11/11/25, with diagnoses including ortho aftercare from fractured left acetabular fracture (hip fracture), left hip pain, repeated falls, and restless leg syndrome. Resident R35's clinical record revealed an admission date of 11/06/25, with diagnoses including ortho aftercare from trans metatarsal amputation, left foot osteomyelitis (bone infection) hyperlipidemia and high blood pressure. Resident R37's clinical record revealed an admission date of 11/06/25, with diagnoses including ortho aftercare from fractured right femur nailing, chronic deep vein thrombus of right leg (blood clot of circulatory system of leg), hyperlipidemia (high levels of fat, including cholesterol and triglycerides, in the blood) and high blood Page 1 of 5 395894 395894 11/21/2025 Meadville Medical Ctr Tcu 1034 Grove Street Meadville, PA 16335

F 0655 Level of Harm - Minimal harm or potential for actual harm pressure. Interview on 11/20/25, at 1:00 p.m. the Director of Nursing (DON) confirmed there was no evidence that a copy of the baseline care plan including physician orders with medications, dietary orders, therapy services was provided to Resident R9, R24, R25, R26, R28, R31, R35 and R37 and/or their representative. 28 Pa. Code 211.10(c) Resident care plan 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services Residents Affected - Many 395894 Page 2 of 5 395894 11/21/2025 Meadville Medical Ctr Tcu 1034 Grove Street Meadville, PA 16335

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 drug manufacturer instructions, and staff interview, it was determined that the facility failed to appropriately date and store medications in one of two nursing medication rooms (Med Room One). Findings include: Observation on 11/18/2025, at 1:20 p.m. in Med Room One, revealed three opened vials of Purified Protein Derivative (PPD-a skin testing agent for tuberculosis) without an open date marked on the vials. A review of the drug manufacturer leaflet indicated a vial of Tubersol which has been entered and in use for 30 days should be discarded. At the time of the observation, the Director of Nursing (DON) confirmed the PPD vials were opened, undated and not dated to indicate when the medication should be discarded. The DON confirmed the PPD vials should have been labeled with an open date to indicate after 30 days of use, the vials would be discarded. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395894 Page 3 of 5 395894 11/21/2025 Meadville Medical Ctr Tcu 1034 Grove Street Meadville, PA 16335

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Potential for minimal harm Based on review of facility policy, facility documentation, clinical records and staff interview, it was determined that the facility failed to ensure that each resident's medical record included documentation that indicated, at a minimum that the resident or resident's representative was provided education regarding the benefits and potential side effects of Influenza/Pneumococcal immunizations; and that the resident either received the Influenza/Pneumococcal immunizations or did not receive the Influenza/Pneumococcal immunizations due to medical contraindications or refusal for eight of eight residents reviewed (Resident R9, R24, R25, R26, R28, R31, R35, and R37). Findings include: Facility policy Influenza Immunization Policy for Inpatients dated 10/15/25, revealed the nurse will assess the patient's immunization status upon arrival to the nursing unit. Vaccine history and updates are entered into the Meditech electronic assessment form and remain in the demo recall system. If the patient meets the criteria, is unsure of vaccination history, the vaccine is not contraindicated, the nurse will document that the vaccine is indicated and initiate vaccine teaching. The nurse will document in the EMR (electronic medical record) that the patient received the current Vaccine Information Statement (VIS). When the patient meets criteria for the vaccine as assessed in the nursing assessment, the vaccine will be added to the e-MAR (electronic medication administration record) by pharmacy. Unless the patient refuses or has a temperature greater than 100.5 degrees Fahrenheit or is one of the exceptions listed above, the nurse will administer the vaccine(s). Facility policy Respiratory Viral Outbreak dated 10/15/25, revealed vaccination is one of the most important ways people can prevent infection, hospitalization, and death from respiratory illness. Encourage everyone to remain up to date with all recommended vaccine doses to protect HCP (health care professional), residents, and visitors. Provide education and resources to HCP, residents, and visitors about the importance of receiving the vaccines for illnesses such as influenza, COVID-19, RSV (respiratory syncytial virus), and pneumonia. Residents R9, R24, R25, R26, R28, R31, R35, and R37's clinical records lacked evidence of a consent process or education provided to the resident and/or resident representative regarding immunization related to the Influenza/Pneumococcal vaccines. During an interview on 11/20/25, at 1:05 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility lacked evidence that each resident's medical record, as noted above, included documentation that indicated, at a minimum that the resident or resident's representative was provided education regarding the benefits and potential side effects of Influenza/Pneumococcal immunization; and that the resident either received the Influenza/Pneumococcal immunization or did not receive the Influenza/Pneumococcal immunization due to medical contraindications or refusal. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(c) Resident care policies Residents Affected - Many 395894 Page 4 of 5 395894 11/21/2025 Meadville Medical Ctr Tcu 1034 Grove Street Meadville, PA 16335

F 0887 Level of Harm - Potential for minimal harm Residents Affected - Many Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on review of facility policy, facility documentation, clinical records and staff interview, it was determined that the facility failed to ensure that each resident's medical record included documentation that indicated, at a minimum that the resident or resident's representative was provided education regarding the benefits and potential side effects of COVID-19 immunization; and that the resident either received the COVID-19 immunization or did not receive the COVID-19 immunization due to medical contraindications or refusal for eight of eight residents reviewed (Residents R9, R24, R25, R26, R28, R31, R35, and R37). Findings include: Facility policy Respiratory Viral Outbreak dated 10/15/25, revealed vaccination is one of the most important ways people can prevent infection, hospitalization, and death from respiratory illness. Encourage everyone to remain up to date with all recommended vaccine doses to protect HCP (health care professional), residents, and visitors. Provide education and resources to HCP, residents, and visitors about the importance of receiving the vaccines for illnesses such as influenza, COVID-19, RSV (respiratory syncytial virus), and pneumonia. Residents R9, R24, R25, R26, R28, R31, R35, and R37's clinical records lacked evidence of a consent process or education provided to the resident and/or resident representative regarding immunization related to the COVID-19 vaccine. During an interview on 11/20/25, at 1:05 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility lacked evidence that each resident's medical record, as noted above. included documentation that indicated, at a minimum that the resident or resident's representative was provided education regarding the benefits and potential side effects of COVID-19 immunization; and that the resident either received the COVID-19 immunization or did not receive the COVID-19 immunization due to medical contraindications or refusal. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(c) Resident care policies 395894 Page 5 of 5