Amoroso Healthcare And Rehabilitation Woodridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrisburg, Pennsylvania.
- Location
- 3625 North Progress Ave, Harrisburg, Pennsylvania 17110
- CMS Provider Number
- 395142
- Inspections on file
- 35
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Amoroso Healthcare And Rehabilitation Woodridge during CMS and state inspections, most recent first.
A resident with spinal stenosis and HTN, who required assistance with toileting and had been provided a bedpan for use with staff and family, was not treated with dignity when a CNA encouraged the resident to urinate in a brief instead of offering the bedpan or assistance to the restroom, and then applied multiple briefs (“double briefing”). This conduct conflicted with facility policy requiring that resident dignity, goals, choices, and preferences be respected at all times, resulting in a deficiency related to respect and quality of life.
Two residents with significant cardiopulmonary conditions were involved in a medication error when an agency LPN brought in medications for both roommates, placed them on their bedside tables, and left without verifying each resident's identity as required by facility policy. One resident noticed a pill she did not take and questioned the medications, leading to the discovery that the medications had been mixed up between the two residents. The DON later confirmed that neither resident actually ingested the other's medications, but the event demonstrated a failure to follow professional standards for safe medication administration and resident identification.
A resident with spinal stenosis and HTN had recently undergone spine surgery, resulting in a stapled incision that was ordered to remain open to air. Despite this order, a nurse aide applied double briefs that covered the surgical site, contrary to the documented wound care requirements. The DON confirmed that the resident’s surgical site was required to be open to air and that briefs should not have been used in a way that covered the incision.
A resident with hypertension and muscle weakness had physician orders for daily Amlodipine and Valsartan-Hydrochlorothiazide, but review of the MAR showed both antihypertensive medications were not administered on one day because the facility was awaiting delivery from the contracted pharmacy. Facility policy states that pharmacy services are available 24/7 and that residents will have a sufficient supply of medications and receive them in a timely manner, yet the DON acknowledged that the ordered medications were not available from the contracted pharmacy.
Surveyors identified that several residents' MDS assessments were inaccurately coded, failing to reflect actual diagnoses, treatments, and care provided. Examples included residents with pressure ulcers not marked at risk, residents on hospice or therapeutic diets not coded as such, antipsychotic medication use not documented, and insulin administration incorrectly recorded. These discrepancies were confirmed by the DON through record review and staff interviews.
Two residents identified as fall risks did not consistently receive care-planned interventions such as fall mats and low bed positioning. Despite documentation and staff awareness, these safety measures were not in place during multiple observations, and leadership confirmed the interventions should have been implemented as outlined in the care plans.
Two residents experienced significant weight loss due to the facility's failure to consistently monitor weights, complete nutritional assessments, and promptly notify providers of changes. One resident on tube feedings and hospice care was not weighed as ordered, and her substantial weight loss was not communicated to her care team. Another resident with dysphagia had gaps in weight documentation and reported receiving unsuitable food, with significant weight loss not promptly addressed. The DON confirmed that staff did not follow physician orders or update care plans as required.
Surveyors found that food items in the kitchen and pantry areas were not consistently labeled or dated, open containers were left unsealed, and some perishable foods were expired or in poor condition. Freezer units were soiled, and temperature logs were incomplete or inaccurately filled. Food from outside sources was not properly labeled with resident information, and staff were unaware of a formal cleaning schedule, all in violation of facility policy and professional standards.
A resident was admitted on multiple psychotropic medications without documentation of informed consent, target behaviors, or monitoring for side effects. Facility policy requiring interdisciplinary evaluation, non-pharmacological interventions, and timely physician response to pharmacy recommendations was not followed, and necessary documentation was missing in the resident's care plan and clinical record.
The facility did not provide required transfer notices or bed hold policy information to several residents with complex medical needs during multiple hospitalizations, as confirmed by record review and staff interviews. The Nursing Home Administrator acknowledged the lack of documentation for these notices, which is not in compliance with facility policy and state regulations.
Two residents requiring total lift and two-staff assistance for transfers did not receive timely help with ADLs as outlined in their care plans. One resident waited in bed for an extended period before being assisted out of bed, while another waited to be put back in bed after dialysis despite using the call light and expressing discomfort. In both cases, staff delayed following the residents' care plans for necessary ADL support.
A nurse was observed preparing to administer famotidine from a bottle that had been opened and used after its manufacturer expiration date. The staff member did not check the expiration date before use, and the expired medication remained in the cart with no replacement available. Facility leadership confirmed the medication should not have been used past expiration.
A resident with depression and COPD was observed multiple times without access to a functioning call bell, despite facility policy and the resident's care plan requiring it to be within reach. Staff interviews revealed the call bell cord was broken and no maintenance request had been made, leaving the resident without a means to call for assistance.
A resident with dementia, repeated falls, and muscle weakness was discharged without sufficient preparation or documentation to ensure a safe transition home. The facility did not confirm that home health or private duty services were arranged, failed to include key information in the discharge summary, and did not document a review of the discharge plan with the resident or representative. Essential details about the resident's living arrangements and recent health events were also missing from the records.
A resident with dementia, repeated falls, and muscle weakness did not receive a timely social services assessment or adequate discharge planning. Required documentation of social service involvement was missing, and there was no evidence that arrangements for home health or private duty care were confirmed prior to discharge. Facility leadership acknowledged that social service activities and documentation were not completed during the resident's stay.
A resident with chronic kidney disease and diabetes was admitted to a facility requiring BiPAP therapy, as indicated in hospital referral paperwork. The facility did not have a spare BiPAP machine, and the oxygen supply company could not deliver one until the next day. The resident requested to return to the hospital if the BiPAP could not be provided, resulting in their transfer back to the hospital. The DON and NHA acknowledged receiving the referral but noted communication limitations with the hospital.
The facility failed to conduct timely and accurate background checks for four employees, including incorrect submissions and lack of checks upon hire. Additionally, the facility did not verify a nurse's license status at the time of hire, relying on employees to report any issues. This violates facility policy and regulatory guidelines.
The facility failed to follow physician orders for two residents, compromising their care. One resident did not receive prescribed insulin doses on multiple occasions, and another did not receive an initial antibiotic dose due to a pharmacy delay. Additionally, a required medication hold was not followed, delaying a dental procedure. These actions violated 42 CFR 483.25 and 28 Pa. Code 211.12(d)(1)(3)(5).
The facility did not complete annual performance reviews for five nurse aides, with evaluations for three aides only completed just before the survey. The DON confirmed that no evaluations were done prior, citing a change in ownership as the reason.
The facility failed to maintain a safe and sanitary environment for infection prevention and control. Residents with indwelling medical devices and wounds lacked appropriate signage for Enhanced Barrier Precautions (EBP). Additionally, an employee did not adhere to PPE protocols for a COVID-19 positive resident. The facility also failed to maintain accurate infection surveillance data from January to August 2024.
A facility failed to provide appropriate care for a resident receiving tube feedings by not labeling the enteral nutrition bottle with the time or date it was opened. The resident, diagnosed with abnormal weight loss and feeding difficulties, had a physician's order for Jevity 1.5 cal feeding. Observations showed the feeding container was unlabeled, contrary to product guidelines. The DON acknowledged the lack of a specific policy for labeling, leading to the deficiency.
The facility failed to secure medications in locked compartments in two resident areas. A pill was found on the floor in the 100 Hall, and another was identified as Amlodipine at the 200-hall nursing station. Staff interviews confirmed the lapses, and the DON acknowledged the expectation for policy adherence.
A resident with a pressure ulcer did not receive the recommended treatment as the facility failed to order Dakin's solution as advised by a wound consultant. Despite repeated recommendations, the treatment orders remained unchanged, leading to a deficiency in care.
A resident with multiple diagnoses was found with medications left at her bedside, despite not having orders for self-administration. An LPN mistakenly believed the resident could self-administer, and medications were signed off as administered before being taken. The DON confirmed the resident's inability to self-administer and emphasized that medications should not be left unattended.
Failure to Provide Dignified Toileting Care and Respect Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to treat a resident with respect and dignity and to provide care in a manner that enhances quality of life. Facility policy titled “Dignity” states that residents are to be treated with dignity and respect at all times and that resident goals, choices, preferences, values, and beliefs are to be respected and honored beginning at admission and throughout the stay. Resident 2, admitted with diagnoses including spinal stenosis and hypertension, required assistance with toileting and had been provided a bedpan upon admission for use with staff and the resident’s daughter. Despite these needs and preferences, a nurse aide (Employee 3) encouraged the resident to urinate in her brief instead of offering the bedpan or assistance with ambulating to the restroom. Documentation from the resident’s daughter on a Grievance/Concern form stated that the aide encouraged the resident to “pee” in her brief and then placed a “pamper” on the resident. An Employee Progress Discipline Notification documented that Employee 3 double-briefed the resident instead of providing the appropriate toileting assistance. These actions did not honor the resident’s dignity or respect her stated toileting needs and preferences, resulting in a violation of the facility’s dignity policy and regulatory requirements.
Failure to Follow Medication Administration Standards and Resident Identification
Penalty
Summary
The facility failed to ensure that medication administration services met professional standards of quality for two residents. Facility policy titled "Administering Medications" required that medications be administered safely and timely as prescribed, and that the individual administering medications verify the resident's identity before giving medications. Resident 1 had diagnoses including COPD and hypotension, and Resident 4 had diagnoses including respiratory failure and atrial fibrillation. An incident report documented that on an evening shift, an LPN (Employee 4), who was an agency-contracted nurse, brought medications for both Resident 1 and Resident 4 into their shared room, placed the medications on the bedside tables, and left without verifying each resident's identity at the time of administration. According to the incident report, Resident 4 noticed a pink and white pill among the medications and stated that those were not her medications. Resident 1 then stated that she takes a pink and white pill. The residents called the nurse back into the room, at which point the LPN realized that the medications had been given to the wrong residents. The Director of Nursing later confirmed that the two residents did not actually take each other's medications. The deficiency centers on the LPN's failure to follow the facility's medication administration policy, specifically the requirement to verify resident identity before administering medications, resulting in a medication error involving two residents with significant cardiopulmonary diagnoses.
Improper Wound Care Following Spinal Surgery Due to Double Briefing
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive plan of care for one resident following spinal surgery. The resident had diagnoses including spinal stenosis and hypertension and had recently been hospitalized for spine surgery, resulting in a wound/incision closed with staples that was ordered to be left open to air. Review of the clinical record showed that the surgical site required exposure to air, but documentation and an Employee Progress Discipline Notification indicated that the nurse aide assigned to the resident applied double briefs, covering the area despite knowledge that the site needed to remain open to air. In an interview, the Director of Nursing confirmed that the resident should not have been provided with briefs covering the surgical site and that the care provided was inconsistent with the resident’s ordered wound care.
Failure to Provide Ordered Antihypertensive Medications Due to Pharmacy Supply Issues
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered routine antihypertensive medications and to ensure pharmaceutical services that accurately acquire, receive, dispense, and administer drugs as required. Facility policy titled “Policy Services Overview,” revised April 2019, states that pharmacy services are available 24 hours a day, seven days a week, and that residents will have a sufficient supply of prescribed medications and receive them in a timely manner. Despite this policy, the facility did not ensure that medications were available and administered as ordered. Resident 2, admitted on February 25, 2026, had diagnoses including hypertension and muscle weakness and had physician orders for Amlodipine Besylate 5 mg by mouth once daily and Valsartan-Hydrochlorothiazide 320-25 mg by mouth once daily for essential hypertension. Review of the Medication Administration Record for February 1–28, 2026, showed that both medications were not administered on February 26, 2026, as ordered. A progress note for that date documented that the medications were not given because the facility was “awaiting delivery,” and that the RN Supervisor, resident representative, and provider were aware. In an interview, the Director of Nursing acknowledged that the ordered medications were not available from the contracted pharmacy.
Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the actual conditions and care provided to six out of nineteen residents reviewed. For one resident with a stage 4 pressure ulcer, the Minimum Data Set (MDS) was incorrectly coded to indicate the resident was not at risk for pressure ulcers, despite clinical records showing otherwise. Another resident with chronic kidney disease, vascular dementia, and a history of weight loss was not coded as receiving a therapeutic diet or hospice care on multiple MDS assessments, even though physician orders and clinical records confirmed these services were being provided. A third resident with atrial fibrillation and chronic respiratory failure was actively receiving an antipsychotic medication, but the MDS did not reflect this medication use. In another case, a resident with a gastrostomy and feeding difficulties was incorrectly coded as having received intravenous fluids, though no documentation supported this. Additionally, a resident admitted to hospice care for chronic respiratory failure and hypoxia was not coded as having an active diagnosis of respiratory failure on the MDS. Finally, a resident with type II diabetes and chronic respiratory failure was coded as receiving insulin injections, but records showed only Ozempic injections were administered, not insulin. These inaccuracies were confirmed through staff interviews, with the Director of Nursing acknowledging the errors in MDS coding for each case. The deficiencies were identified through clinical record reviews and staff interviews, demonstrating a pattern of inaccurate resident assessments that did not align with the residents' actual diagnoses, treatments, and care needs as documented in their clinical records.
Failure to Implement and Maintain Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement and maintain appropriate interventions to prevent accidents for two residents identified as being at risk for falls. For one resident with chronic kidney disease, vascular dementia, and a history of failure to thrive, the care plan included interventions such as bilateral body pillows, keeping the bed in the lowest position, and placing fall mats on both sides of the bed. Despite these interventions being documented in the care plan following a fall from bed, repeated observations showed that the bed remained approximately two feet off the floor and fall mats were not present as required. Staff interviews revealed that the interdisciplinary team had decided against the use of fall mats, but they were still included in the care plan and thus should have been implemented. The bed provided by hospice could not be lowered further, and staff had communicated this limitation to administration multiple times. Another resident with chronic obstructive pulmonary disease and depression was also identified as being at risk for falls, with care plan interventions specifying a fall mat to the right side of the bed and keeping the bed in the lowest position. After an unwitnessed fall, it was documented that neither the fall mat was present nor was the bed in the lowest position at the time of the incident. Subsequent observations confirmed that these interventions continued to be absent, with the resident found in bed without a fall mat and the bed not in the lowest position. Interviews with facility leadership confirmed that the expected interventions, as outlined in the residents' care plans, were not consistently implemented. The failure to provide and maintain these interventions, despite being care planned and necessary for the residents' safety, constituted a deficiency in ensuring the environment was free from accident hazards and that adequate supervision and assistance were provided to prevent accidents.
Failure to Monitor and Communicate Significant Weight Loss in Two Residents
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of nutritional status for two residents, resulting in deficiencies related to weight monitoring and timely notification of significant weight loss. For one resident with chronic kidney disease, vascular dementia, and a history of failure to thrive, there were physician orders for monthly weights and tube feedings. However, weight documentation was missing for several months, and the resident experienced a significant weight loss of 24 pounds in June, which was not communicated to the physician, hospice provider, or family. Additionally, no nutritional assessments were completed by the facility dietician for an extended period, and the hospice and facility staff did not document or address the weight loss until months later, despite ongoing tube feedings and changes in the resident's oral intake. Another resident with a history of infection, dysphagia, and repeated falls reported weight loss due to receiving food that was not suitable for his needs or preferences. The care plan included interventions for regular weight monitoring and notification of significant changes to the medical doctor and dietitian. Despite physician orders for daily, weekly, and then monthly weights, there was a gap in weight documentation, and a significant weight loss of 5.1% was recorded over a two-week period. The facility obtained a reweigh after noticing the discrepancy, but the reweigh was not completed within the expected timeframe. Interviews with the DON revealed that the facility's weight policy was not aligned with current professional standards, and staff did not consistently follow physician orders for weight monitoring. The DON acknowledged that residents on hospice should still have been weighed according to orders and that significant weight loss should have been communicated to the appropriate providers and representatives. The lack of timely documentation, assessment, and communication contributed to the deficiencies identified for both residents.
Deficient Food Storage and Equipment Sanitation Practices
Penalty
Summary
The facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and all three pantry areas. Observations revealed multiple instances of food items, such as pasta, steak fries, hot dogs, sausages, and sausage patties, that were open and not labeled or dated as required by facility policy. Freezer units were found to be soiled with food debris, and staff interviews indicated a lack of awareness regarding a formal cleaning schedule for kitchen equipment. Additionally, food from outside sources was not consistently labeled with resident names or dates, and some perishable items were found past their expiration dates or in poor condition, such as a bag of food that appeared rotten and a container of wilted salad with a foul odor. Temperature logs for refrigerators and freezers in the pantry areas showed missing entries on several dates, and in one instance, temperatures were pre-filled for a future date. Other deficiencies included an ice cream container without a lid, frozen beverages and meals from outside sources not properly labeled, and open containers of food not properly sealed. The Nursing Home Administrator confirmed the expectation that expired items are discarded, food items are labeled and dated per policy, and equipment is maintained according to professional standards, but these expectations were not met as evidenced by the survey findings.
Failure to Ensure Proper Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications. Upon review, it was found that a resident was admitted with multiple psychotropic medications, including duloxetine, mirtazapine, sertraline, and quetiapine. The clinical record did not contain documentation of education provided to the resident or their representative regarding the risks and benefits of these medications, nor was there evidence of informed consent for their administration. Additionally, there was no documentation of identified target behaviors, behavior monitoring, or side effect monitoring related to the use of the antipsychotic medication. The facility's policies require an interdisciplinary evaluation before initiating, modifying, or discontinuing psychotropic medications, as well as the use of non-pharmacological interventions and obtaining informed consent. Despite these requirements, the resident's care plan did not identify target behaviors, and there was no evidence that non-pharmacological alternatives were considered or discussed. The facility also failed to document any rationale for duplicate therapy or to ensure that medications prescribed by specialists were clinically indicated and properly documented. A consultant pharmacist issued a recommendation to the resident's physician to review the use of antipsychotic medication due to black box warnings and lack of a supporting diagnosis. However, there was no timely physician response or documentation addressing this recommendation. The resident's practitioner did not consult psychiatric services until several weeks after the pharmacist's recommendation, and there was no documentation of actions taken during multiple practitioner visits. Facility leadership confirmed that required monitoring and documentation were not completed at the time of admission.
Failure to Provide Required Transfer Notices and Bed Hold Policy Information
Penalty
Summary
The facility failed to provide required transfer notices and bed hold policy information to residents or their representatives upon transfer or discharge, as mandated by facility policy and state regulations. Specifically, for three residents with significant medical conditions, including congestive heart failure, chronic kidney disease, vascular dementia, atrial fibrillation, infection following a procedure, dysphagia, and repeated falls, there was no documentation that they or their representatives received written notice of transfer or the facility's bed hold policy during multiple hospitalizations and returns. Facility policy requires that all residents or their representatives receive written information about bed hold policies both in advance of any transfer and at the time of transfer, or within 24 hours if the transfer is emergent. Clinical record reviews for these residents showed multiple instances of hospital transfers due to acute medical changes, but no evidence was found that the required notices were provided. The Nursing Home Administrator confirmed that there was no proof these notices were sent for the identified transfers. This deficiency was identified through facility policy review, clinical record review, and staff interviews, and is a violation of 28 Pa. Code 201.14(a) regarding the responsibility of the licensee.
Failure to Timely Assist Residents with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. For one resident with diagnoses including dysphagia and hypertension, the care plan specified total lift and two-staff assistance for transfers, as well as a preference to be out of bed in a chair after being changed and specific times for getting up and going to bed. Despite these documented interventions, the resident was observed still in bed late in the morning, waiting to be assisted out of bed, with staff confirming the delay. The resident remained in bed for an extended period before two staff members eventually arrived with a lift to assist. Another resident, diagnosed with chronic obstructive pulmonary disease and depression, also required total lift and two-staff assistance for transfers, with a care plan intervention to be offered a rest period in bed after returning from dialysis. This resident was observed with the call light on, requesting to be put back in bed after returning from dialysis and expressing not feeling well. Staff entered the room, turned off the call bell, and left, stating they would get someone to assist. The resident remained waiting for assistance for a significant period before two staff members arrived with a lift to help. In both cases, the care plans were not followed in a timely manner, resulting in delays in providing necessary ADL support.
Expired Medication Not Discarded from Medication Cart
Penalty
Summary
Nursing staff failed to discard an expired medication in a timely manner, as observed during a medication pass on Unit 2. An employee retrieved a house stock bottle of famotidine 10 mg from a medication cart to administer to a resident. The bottle had an open date of March 4, 2025, but the manufacturer expiration date was January 2025, indicating the medication was opened and used after its expiration. The employee did not check the expiration date before preparing the medication for administration, and confirmed during an interview that the bottle had been in use past its expiration date, with no other bottles available in the cart. Facility policies require nursing staff to maintain medication storage areas in a safe and sanitary manner and to check expiration dates prior to administering medications. Both the Nursing Home Administrator and the Director of Nursing confirmed that the medication should not have been used past its expiration date. The surveyor's findings were based on policy review, direct observation, and staff interviews, and the expired medication was found to be approximately one-third full at the time of discovery.
Resident Lacked Access to Functioning Call Bell
Penalty
Summary
A deficiency was identified when a resident diagnosed with depression and chronic obstructive pulmonary disease was observed lying in bed without access to a functioning call bell. Multiple observations confirmed that the call bell was neither attached nor accessible to the resident over a period of time. The resident's care plan specifically required that the call bell be within reach, and facility policy mandated that call lights be plugged in and functioning at all times. Staff interviews revealed that the call bell cord had broken off and no maintenance request had been submitted to address the issue. The staff member interviewed was unaware of the problem until it was brought to their attention during the survey. The Nursing Home Administrator confirmed that the resident should have had access to a call bell and was unable to determine how long the device had been nonfunctional.
Failure to Ensure Safe and Documented Discharge Planning
Penalty
Summary
The facility failed to provide and document adequate preparation for a safe and orderly discharge for a resident, as well as failed to provide a comprehensive discharge summary that included a post-discharge plan of care and post-discharge services. Facility policy required that each resident have an individualized discharge plan developed by the interdisciplinary team, with input from the resident and their representative, to ensure a safe transition and that the discharge summary be furnished to the next care provider. However, review of the clinical record and staff interviews revealed that these requirements were not met for one resident. The resident in question had a history of atrial fibrillation, dementia with behavioral disturbance, repeated falls, and generalized muscle weakness. She was admitted after a fall that resulted in facial injuries and required 24-hour support due to her dementia. Throughout her stay, progress notes indicated ongoing confusion and a need for supervision and cueing. Although there were discussions about her care needs at home and plans to arrange for private home care assistance and home health services, there was no documentation that these services were actually set up prior to discharge. Additionally, the discharge summary lacked essential information such as the name and contact information for the home health agency and primary care physician, and did not document the resident's living arrangements post-discharge. Further, the discharge summary was incomplete in several sections, including dietary services, and failed to mention a significant unresponsive episode that occurred shortly before discharge. Interviews with facility leadership confirmed that there was no documentation of a review or assessment of the discharge plan to ensure all necessary measures were in place for the resident's safety. The facility was also without a social worker at the time, and social service responsibilities were being covered by other staff, which contributed to the lack of proper documentation and follow-through.
Failure to Provide Timely Social Services Assessment and Discharge Planning
Penalty
Summary
The facility failed to provide sufficient and timely medically-related social services for a resident during the admission and discharge planning process. Facility policy required a social assessment to be completed within fourteen days of admission to identify the resident's needs and to assist in developing a personalized care plan. However, the resident's clinical record showed that the Social Services Evaluation at admission was left blank, and there was no documented social service assessment during the resident's stay. This omission meant that the resident's personal and social needs, as well as potential problems, were not formally identified or addressed as part of the care planning process. The resident in question was admitted with multiple diagnoses, including atrial fibrillation, dementia with behavioral disturbance, repeated falls, and generalized muscle weakness. Throughout the stay, progress notes indicated ongoing confusion and a need for 24-hour support due to dementia. The care plan included a focus on cognitive decline, impaired vision, communication problems, self-care deficits, limited mobility, and a desire to discharge back to the community. Despite these complex needs, there was no documentation of social services involvement in discharge planning, such as arranging for home health services, private duty care, or ensuring that the resident's transition back to the community was safe and supported. Upon discharge, documentation was incomplete regarding the arrangements made for the resident's care at home. The discharge summary noted a referral for home health but did not include the agency's name or contact information, nor did it specify the resident's living arrangements or confirm that necessary services were in place. Interviews with facility leadership revealed that social service activities were being covered by the NHA and Admissions Coordinator due to a vacancy in the social worker position, and that key documentation and assessments were missed. There was no evidence of a review or assessment of the discharge plan to ensure the resident's needs would be met after leaving the facility.
Failure to Provide Required Respiratory Care
Penalty
Summary
Amoroso Healthcare and Rehabilitation Woodridge was found to be non-compliant with the requirement for providing respiratory care consistent with professional standards of practice. The deficiency involved a resident who was admitted to the facility with a need for BiPAP therapy, as indicated in the hospital referral paperwork. The resident, who had chronic kidney disease and diabetes, was admitted to the facility in the evening with a documented need for BiPAP at night and as needed during the day. However, upon admission, the facility did not have a spare BiPAP machine available, and the oxygen supply company could not deliver one until the following day. The situation escalated when the resident requested to be sent back to the hospital if the BiPAP could not be provided for the night, leading to the resident's transfer back to the hospital. During an interview, the Director of Nursing and the Nursing Home Administrator acknowledged receiving the referral that mentioned the need for BiPAP but noted that the hospital used Careport for communication, which did not involve verbal communication with the facility. The responsibility for reviewing and approving referrals was shared among the DON, NHA, and Director of Social Services.
Plan Of Correction
1. Resident #5 no longer resides in the facility. 2. An audit will be completed by the Resident Care Navigator or designee of the last 30 days of admissions to determine if residents admitted needed a bipap received one at admission. Corrections will be made as necessary. 3. Education will be provided to the NHA, DON, and Resident Care Navigator regarding the following new process. Referrals will be reviewed by the NHA, DON, Resident Care Navigator or designee to determine if a bipap is needed and the Resident Care Navigator or designee will confirm with the hospital Case Manager the need for a bipap at admission. This information will be discussed at the clinical meeting and arrangements will be made to obtain the needed equipment prior to admission. Equipment needs and settings will be documented in the resident's medical record. 4. A new admission tracker will be kept by the Resident Care Navigator with the information needed to admit a resident with a bipap. This tracker will be reviewed weekly x four by the NHA or designee for accuracy. Results of the tracker review will be reviewed at the monthly Quality Assurance Committee meeting.
Failure to Conduct Timely Background Checks and License Verifications
Penalty
Summary
The facility failed to conduct timely, complete, and accurate background investigations for four out of five employee files reviewed. Employee 7 was hired without a complete criminal background check, as the facility submitted incorrect personal information and omitted the social security number. Employee 8 and Employee 9 were hired without any criminal background checks conducted upon hire, with checks only completed months prior to their hiring dates. Employee 11 was also hired without a criminal background check upon hire, and the facility failed to verify that Employee 11's Registered Nurse license was unencumbered at the time of hire. The Director of Nursing confirmed during interviews that the facility should conduct criminal background checks and professional license verifications upon hire. However, the responsibility for alerting the facility to any criminal convictions or actions against a professional license was placed on the employee. This lack of proper background checks and license verifications upon hiring is a violation of the facility's policy and regulatory guidelines, as outlined in the 28 Pa code 201.18(b)(1)(3) Management.
Failure to Follow Physician Orders for Two Residents
Penalty
Summary
The facility failed to adhere to physician orders for two residents, compromising their care. Resident 22, diagnosed with chronic kidney disease, congestive heart failure, and type 2 diabetes mellitus with diabetic polyneuropathy, had specific insulin administration orders based on blood sugar levels. However, on multiple occasions in July, August, and October 2024, Resident 22 did not receive the prescribed insulin doses despite having blood sugar levels that required it. The facility's records did not indicate any refusal of medication by the resident, which was expected to be documented if it occurred. Resident 72, with diagnoses including hypertension and peripheral vascular disease, was prescribed clindamycin for a dental abscess. The initial 600 mg dose was not administered due to a delay in receiving the medication from the pharmacy, and the resident did not start the prescribed regimen until the following day. Additionally, Resident 72 was scheduled for a dental procedure requiring the cessation of Apixaban five days prior, but this was not followed, resulting in the procedure being postponed. The oversight occurred after the resident's return from a hospital visit, where the hold order was not continued. These deficiencies highlight the facility's failure to provide the highest practical well-being by not following physician orders, as required by 42 CFR 483.25 and 28 Pa. Code 211.12(d)(1)(3)(5). The lack of proper documentation and timely medication administration contributed to the deficiencies observed during the survey.
Failure to Conduct Timely Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete a performance review for nurse aide staff at least once every 12 months for five employees. The review of facility documentation showed that Employees 1, 2, 3, 4, and 5 had not received timely performance evaluations. Employee 1 was hired in 1999, Employee 2 in 2019, Employee 3 in 2007, Employee 4 in 2011, and Employee 5 in 2006. On October 16, 2024, the surveyor was provided with performance evaluations for Employees 2, 3, and 5, all dated October 15, 2024, indicating they were completed just before the survey. No evaluations were provided for Employees 1 and 4. The Director of Nursing confirmed that no performance evaluations had been completed prior to October 15, 2024, attributing the delay to a recent change in ownership and the decision to start staff evaluations anew.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a safe and sanitary environment that supports infection prevention and control for several residents. Observations revealed that residents with indwelling medical devices and wounds, who should have been on Enhanced Barrier Precautions (EBP), did not have appropriate signage on their room doors indicating such precautions. This included residents with indwelling catheters, pressure ulcers, and gastrostomy tubes. The Director of Nursing (DON) confirmed that these residents should have been on EBP according to facility policy. Additionally, the facility did not adhere to its policy regarding the use of Personal Protective Equipment (PPE) for residents with COVID-19. An employee was observed entering a COVID-19 positive resident's room wearing only a surgical mask and disposable gown, contrary to the policy requiring an N95 mask, gown, gloves, and eye protection. The DON acknowledged that the facility policy should have been followed in this instance. The facility also failed to maintain an accurate data collection system for infection surveillance from January 2024 through August 2024. The DON was unable to access infection surveillance data for the first half of the year due to a change in facility ownership and could not locate data for July and August 2024. This lack of data collection and access further compromised the facility's ability to monitor and control infections effectively.
Failure to Label Enteral Nutrition Bottles
Penalty
Summary
The facility failed to provide appropriate care and services to a resident receiving tube feedings, as observed in the case of a resident with diagnoses of abnormal weight loss and feeding difficulties. The facility's policy on Enteral Nutrition, revised in November 2018, did not include any guidelines for labeling an enteral nutrition bottle with the time or date it was opened and placed into use. Observations on two consecutive days revealed that the tube feeding container beside the resident's bed was not labeled with the time or date of opening or when the administration began. The resident had a physician's order to receive enteral feeding, Jevity 1.5 cal, at a specified rate and time. However, the product information for Jevity 1.5 cal indicated that once opened, the product should be used within 48 hours with clean techniques or discarded after 24 hours. The Director of Nursing confirmed that the facility lacked a specific policy for labeling and dating enteral nutrition, although the expectation was for nurses to date the bottle when placed into use. This oversight in labeling and dating the enteral nutrition bottle led to the deficiency identified by the surveyors.
Medication Storage Deficiency in Resident Areas
Penalty
Summary
The facility failed to ensure that drugs were stored in locked compartments and were only accessible by authorized personnel in two of the three resident areas observed, specifically the 100 Hall and 200 Hall. During an observation on October 15, 2024, a round, white object was found on the floor in a resident's room in the 100 Hall. Employee 6, a Registered Nurse, confirmed the object was a medication pill but was unable to determine its type or origin. The Director of Nursing (DON) was informed of the incident and acknowledged the issue. On October 16, 2024, another observation at the 200-hall nursing station revealed a round white pill with '210' inscribed on it, identified as Amlodipine 5 mg, a blood pressure medication. Employee 13, a Registered Nurse Supervisor, indicated that a nurse had been wasting medication and likely dropped the pill. The DON expressed an expectation that facility policy should have been followed to secure the medication, as per the facility's policy on the disposal of medications and medication-related supplies.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent infection of a pressure ulcer for a resident diagnosed with schizophrenia, major depressive disorder, and anxiety. The resident was being followed weekly by an outside wound consultant for an unstageable pressure ulcer on the sacrum. On July 23, 2024, the wound consultant recommended a new treatment plan that included cleansing the wound with 0.125% Dakin's solution, applying Santyl, and using a silver alginate dressing. However, the physician's orders only included cleansing with normal saline solution, Santyl, and silver alginate, omitting the Dakin's solution. The same treatment recommendation was made by the wound consultant on July 30, 2024, but no new treatment orders were placed, and the previous orders remained unchanged. During an interview on August 20, 2024, the Director of Nursing was unable to explain why the Dakin's solution was not ordered. This oversight indicates a failure to follow the wound consultant's recommendations, which is inconsistent with professional standards of practice and resulted in a deficiency in the care provided to the resident.
Medication Administration Protocol Breach
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards for a resident diagnosed with congestive heart failure, gastroesophageal reflux disease, and hypertension. The resident's clinical record indicated that she was prescribed several medications, including Clopidogrel, Famotidine, Jardiance, MagOx, Metoprolol, Lasix, Eliquis, and Florastor. However, during an observation, it was noted that a cup of these medications was left on the resident's bedside table, which was against the facility's protocol as the resident was not authorized to self-administer medications. A Medication Self-Administration Screen had previously determined that the resident was unable to safely administer her medications. An interview with an LPN revealed a misunderstanding, as the nurse believed the resident had an order to self-administer her medications. The medications were signed off as administered before the resident had taken them, which was confirmed by the DON. The DON also acknowledged that the resident sometimes refused medications if staff stayed to watch her, but reiterated that there were no orders for self-administration and that medications should not be left at the bedside. This incident highlights a lapse in adherence to medication administration protocols and communication within the facility.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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