Aristacare At Meadow Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in Plymouth Meeting, Pennsylvania.
- Location
- 845 Germantown Pike, Plymouth Meeting, Pennsylvania 19462
- CMS Provider Number
- 395019
- Inspections on file
- 34
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 20 (2 serious)
Citation history
Health deficiencies cited at Aristacare At Meadow Springs during CMS and state inspections, most recent first.
A resident with multiple complex conditions, including HTN, intracerebral hemorrhage, hemiplegia, tracheostomy, gastrostomy, respiratory failure, DM, and aphasia, had physician orders for vital signs every shift and several cardiac medications. Over several days, staff documented multiple pulse readings at or below the lower limit of the normal adult range, yet the physician and the resident’s representative were not notified of these changes in condition. The DON, an LPN, and a respiratory therapist confirmed both the abnormal pulse readings and the lack of required notification, in violation of facility policy and state regulations.
A resident with multiple complex conditions, including HTN, intracerebral hemorrhage, hemiplegia, tracheostomy, gastrostomy, respiratory failure, DM, and aphasia, was admitted with MD orders for VS monitoring every shift and several cardiac medications (amlodipine, aspirin, atorvastatin, Eliquis, lisinopril, metoprolol). The facility did not develop a required 48-hour admission care plan that addressed the resident's cardiac disease, cardiac medication use, or parameters for VS monitoring, and the DON confirmed the lack of such care planning.
A resident with complex medical needs did not receive IV fluids in a timely manner after physician orders were placed, with an eight-hour delay in starting fluids and further delays after the IV became dislodged. Nursing staff did not attempt reinsertion and relied on a contracted IV team, resulting in missed doses of fluids and medications. The resident was ultimately transferred to the hospital with septic shock and pneumonia due to the facility's failure to ensure continuous IV fluid administration.
A resident with multiple complex medical conditions, including quadriplegia and Parkinson's disease, was found to have unmet hygiene needs, such as a dry, flaky scalp and uncut nails. Despite physician orders for medicated shampoo and documented family concerns, the care plan lacked goals or interventions for hair and nail care. Observations confirmed the ongoing hygiene issues, and facility leadership acknowledged the deficiency.
A facility failed to provide a resident and their representative with written notice of the bed-hold policy during a transfer to the hospital for low hemoglobin levels. The clinical record lacked documentation of this notice, and the Nursing Home Administrator confirmed the absence of a system to ensure such notice was given.
A facility failed to update the care plan for a resident with a left wrist dislocation. The resident, who was severely cognitively impaired and dependent on staff for transfers, was advised by an orthopedic physician to have the wrist immobilized and to use caution during transfers. However, the care plan was not revised to include these instructions, violating the facility's policy on care plan updates.
A facility failed to provide necessary treatment and services for a resident with hand contracture. The resident, fully dependent on staff for personal hygiene, was observed with contracted upper extremities, soiled fingernails, and reddened palms. Despite being a candidate for adapted equipment to prevent further contracture and skin breakdown, the facility did not provide these interventions, leading to a deficiency in care.
A facility failed to provide timely treatment for a resident with a gastrojejunostomy tube feeding, leading to complications. The resident, who was severely cognitively impaired, experienced repeated tube dislodgement and a worn insertion site. Despite a care plan for a gastrointestinal evaluation, the consultation was delayed, resulting in the resident being sent to the hospital for surgical treatment. The director of nursing confirmed the delay in the consultation, highlighting a deficiency in the facility's care.
A facility failed to provide trauma-informed care for a resident with PTSD by not identifying the resident's triggers or addressing their past experiences in the care plan. The care plan did not adequately reflect the resident's condition, leading to a deficiency in culturally competent care.
A facility failed to monitor and document the use of psychotropic medication for a resident, as required by their policy. The resident, who was cognitively intact and had diagnoses including seizure disorder and depression, was prescribed Hydroxyzine HCL for anxiety without documentation of a limited fourteen-day use or rationale for extended use. A psychiatrist noted the resident's sadness due to missing family, not anxiety. A nurse confirmed the lack of necessary documentation.
Essential kitchen equipment was found to be inefficient, with a three-compartment sink unable to hold sanitizing solution due to leaks and missing components. Additionally, metal doors leading outside did not seal properly, allowing pest access, and rodent droppings were observed in the dry food storage area.
A resident's care plan was not updated to reflect a new tuberculosis diagnosis, despite the facility being notified and taking isolation precautions. The care plan lacked specific interventions for the diagnosis, and this deficiency was confirmed by the DON.
A resident tested positive for TB, and while the facility reported the case to the local county and implemented measures, it failed to notify the Pennsylvania DOH through the state Event Reporting System. This deficiency was confirmed by both the DON and the Nursing Home Administrator.
A resident with a replaced dislodged DOB tube, aspiration pneumonitis, and respiratory failure had specific physician's orders for Metoprolol tartrate and Midodrine. The facility failed to follow these orders when a nurse administered Midodrine despite the resident's blood pressure being above the threshold to hold the medication. Additionally, the medication was held when the resident's blood pressure was below the threshold, contrary to the physician's orders.
A facility failed to complete a STAT doppler study for a resident with acute pain and swelling in the left arm. Despite an order for an emergency doppler study, there was no documentation of its completion. The resident, who had been readmitted with a replaced dislodged DOB tube, aspiration pneumonitis, and respiratory failure, was later admitted to the hospital for hypotension and gastrointestinal bleeding.
A facility failed to document blood pressure and medication administration for a resident with specific physician orders for Metoprolol tartrate and Midodrine. The nurse did not record the blood pressure or medication administration on one occasion and failed to document holding the medication as per orders on another occasion, leading to a deficiency.
The facility did not notify the State Long-Term Care Ombudsman of emergency transfers and discharges for several residents. These residents were transferred to hospitals due to medical emergencies like abnormal vital signs and respiratory distress, but there was no documentation of the required notifications.
A resident with multiple pressure ulcers did not receive consistent wound care treatments as prescribed, with several lapses documented in the facility's records. The resident, who required total assistance and had a history of neurogenic bladder, paraplegia, and other conditions, was admitted with unstageable pressure ulcers. Despite having a care plan, treatments were not administered on multiple occasions. Additionally, there was a grievance about improper use of a specialty mattress, with staff failing to position the resident correctly and turning off the mattress during care.
A resident with neurogenic bladder and other conditions did not receive timely continence care, as required by their care plan. Despite being cognitively intact and dependent on staff for toileting, the resident experienced delays in care, leading to grievances filed by the resident and their family. The facility failed to document refusals of care and did not provide timely assistance, resulting in the resident remaining unclean for extended periods.
The facility failed to maintain safe water temperatures in resident bathroom hand sinks and showers, with temperatures recorded as high as 124 degrees Fahrenheit. Staff were unaware of the correct temperature limits and did not have thermometers available, leading to an Immediate Jeopardy situation for residents' safety.
A resident with a history of impaired skin integrity and multiple medical conditions had physician orders to wear prevalon boots and offload heels with pillows while in bed. However, these measures were not consistently followed, leading to the re-opening of a stage 3 pressure ulcer on the resident's right heel. The wound care nurse confirmed that the heel boot was not always on, and the pillow was not always propped up under the knee, resulting in the wound not improving.
The facility failed to provide proper respiratory care for three residents by not having an ambu bag and emergency kit at the bedside, improperly storing ambu bags, and not dating aerosol tubing as required by facility policy.
The NHA and DON failed to manage hot water temperatures, resulting in an Immediate Jeopardy situation. Water temperatures in resident bathroom sinks and shower rooms were above 110 degrees Fahrenheit, placing residents at risk for serious injury from burns.
The facility failed to ensure accurate documentation for a resident, resulting in an erroneous pulmonary progress note being entered into the resident's clinical record. The note, completed by a physician not assigned to the resident, contained information about a different patient, which was confirmed by the Nursing Home Administrator and the Director of Nursing.
The facility failed to maintain effective infection control practices during medication administration and wound care for two residents. A nurse was observed with an uncapped insulin syringe and struggled with a Foley catheter, contaminating it with her cell phone. Another nurse used the same gauze piece to cleanse both the inside and outside of a wound, violating infection control protocols.
Failure to Notify Physician and Representative of Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and the resident’s responsible party of a significant change in a resident’s medical condition, as required by facility policy. The written policy stated that nursing supervisors must notify the attending physician and the resident’s representative of significant changes in the resident’s medical, physical, emotional, or mental condition, any need to alter treatment, and must document these changes in the medical record. For one resident with multiple serious diagnoses, including hypertension, non-traumatic intracerebral hemorrhage, hemiplegia/hemiparesis, tracheostomy, gastrostomy, respiratory failure, diabetes mellitus, and aphasia, the physician had ordered vital signs to be monitored every shift and prescribed several cardiac-related medications, including antihypertensives and anticoagulants. Clinical record review showed multiple pulse readings for this resident over several days, with values both within and below the normal adult range of 60–100 beats per minute, as identified by staff. On specific dates, the resident’s pulse was documented as low as 50–59 beats per minute at various times. Interviews with the DON, an LPN, and a respiratory therapist confirmed the documented pulse readings and that the physician was not notified of these irregular pulse values on the identified days. The LPN and respiratory therapist each acknowledged awareness of the normal adult pulse range and confirmed that the physician had not been alerted to the changes in the resident’s medical status, constituting noncompliance with the facility’s own change-in-condition notification policy and applicable state regulations.
Failure to Develop 48-Hour Admission Care Plan for Cardiac Management
Penalty
Summary
The facility failed to develop and implement a care plan within 48 hours of admission that addressed a resident's cardiac disease, cardiac medications, and ordered vital sign monitoring. The resident was admitted on March 5, 2026, at 15:20 with multiple diagnoses, including hypertension, non-traumatic intracerebral hemorrhage, hemiplegia and hemiparesis of the non-dominant side, tracheostomy, gastrostomy, respiratory failure, diabetes mellitus, and aphasia. The physician ordered vital signs to be monitored every shift and prescribed several cardiac-related medications, including amlodipine besylate and lisinopril for hypertension, aspirin for prophylaxis, atorvastatin for hyperlipidemia, Eliquis for cerebrovascular accident, and metoprolol tartrate for hypertension. Clinical record review showed that the required care plan was not developed within 48 hours of admission and did not include health care related to the resident's cardiac disease, the use of cardiac medications, or parameters for vital sign monitoring. An interview with the DON confirmed the absence of a care plan addressing these areas for this resident. The deficiency was cited under 28 PA. Code 211.12(d)(5) for nursing services.
Failure to Timely Administer IV Fluids and Maintain IV Access
Penalty
Summary
A deficiency occurred when intravenous (IV) fluids ordered for a resident with multiple complex medical conditions, including non-traumatic brain dysfunction, hyponatremia, cerebral palsy, seizure disorder, and respiratory failure, were not administered in a timely manner. The resident was dependent on a tracheostomy, ventilator, supplemental oxygen, and enteral feeding, and was totally dependent on staff for all activities of daily living. Physician orders were placed for IV fluids to address hypernatremia and dehydration, as laboratory results showed elevated sodium and BUN/creatinine levels consistent with dehydration. Despite the order for IV fluids being placed at 8:30 a.m., the fluids were not started until after 4:00 p.m., resulting in an approximately eight-hour delay. The nurse responsible for the resident could not provide an explanation for the delay in starting the fluids. The resident’s IV line later became dislodged the following morning, and the nurse did not attempt to reinsert the IV, instead contacting the contracted IV team. This further delayed the administration of fluids and prescribed medications, as the contracted team was not immediately available and the resident required both fluids and antibiotics. Documentation revealed inconsistencies in the nurse’s account of the difficulty of IV insertion, as progress notes indicated the initial IV was placed without complication. The delay in reestablishing IV access and the subsequent lack of timely fluid and medication administration contributed to the resident’s transfer to the hospital, where the resident was admitted with septic shock and multifocal pneumonia. The facility failed to ensure continuous and timely IV fluid administration as ordered.
Failure to Develop and Implement Hygiene Care Plan for Dependent Resident
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a care plan addressing hygiene care, specifically hair and nail care, for a resident with significant medical needs. The resident, a male with quadriplegia, Parkinson's disease, myocardial infarction, malnutrition, heart failure, chronic kidney disease stage 3, gastrostomy status, dysphagia, and a history of nontraumatic intracerebral hemorrhage, was admitted to the facility and was dependent on staff for activities of daily living. Despite a physician's note documenting family concerns about the resident's dry, flaky scalp and a subsequent order for medicated shampoo to address tinea versicolor, there was no evidence in the care plan of goals or interventions related to hair and nail care for this dependent resident. Observations confirmed the presence of yellow flakes on the resident's oily scalp and uncut nails, indicating that hygiene needs were not being met. The findings were corroborated by the facility's director of nursing and wound care nurse. Review of the facility's care plan policy showed that care plans are intended to address identified problem areas to maintain the highest level of resident functioning, but in this case, the care plan did not include necessary interventions for the resident's hygiene care.
Failure to Provide Bed-Hold Policy Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of the bed-hold policy to a resident and their representative during a facility-initiated transfer to a hospital. Specifically, Resident R100 was transferred to the hospital emergency room due to low hemoglobin levels. Upon review of Resident R100's clinical record, there was no documented evidence that the resident and their representative received written notice of the facility's bed-hold policy, which should include information on the duration of the bed-hold, bed hold reserve payment, and the conditions for returning to a bed at the facility. An interview with the Nursing Home Administrator confirmed that there was no system in place to ensure that such notice was provided at the time of transfer.
Failure to Update Care Plan for Resident with Wrist Dislocation
Penalty
Summary
The facility failed to update and revise the care plan for a resident who suffered a left wrist dislocation. The resident, who was severely cognitively impaired and dependent on staff for transfers, was diagnosed with the wrist dislocation on September 19, 2024. The orthopedic physician recommended treating the dislocation with immobilization and advised the facility staff to exercise caution during transfers. However, the resident's care plan was not updated to reflect these new instructions, which was a requirement according to the facility's policy on ongoing care plan updates. This oversight was identified during a clinical record review, highlighting a deficiency in the facility's adherence to its own policies and procedures for maintaining comprehensive care plans.
Failure to Provide Appropriate ROM Treatment for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident, identified as Resident R85, who exhibited a contracture of the hand. The facility's policy on activities of daily living required that residents receive necessary assistance and special equipment for their care needs. However, a review of Resident R85's clinical records revealed that the resident had functional impairments in both upper and lower extremities and was fully dependent on staff for personal hygiene and bathing. Despite these needs, observations showed that the resident had contracted upper extremities and was sitting in a geriatric chair with long, soiled fingernails and reddened palms with peeling and flaking skin. An interview with the physical therapist confirmed that Resident R85 was an appropriate candidate for adapted equipment, such as palm guards and lambs wool, to prevent skin breakdown and assist with further contracture development. The facility's failure to provide these necessary interventions and equipment contributed to the resident's condition, indicating a deficiency in the care provided to maintain or improve the resident's range of motion and prevent further decline.
Failure to Provide Timely Gastrointestinal Consultation for Tube Feeding Complications
Penalty
Summary
The facility failed to provide appropriate and timely treatment for a resident with a gastrojejunostomy tube feeding, leading to complications. The resident, who was severely cognitively impaired, had a history of tube feeding dislodgement and a worn and stretched insertion site. Despite a care plan to have the resident evaluated by a gastrointestinal physician for a different insertion site, the consultation was not conducted as scheduled. This delay in evaluation and treatment contributed to the resident being sent to the hospital for surgical treatment of the tube feeding site. The clinical records indicated that the resident's tube feeding had to be replaced multiple times due to dislodgement and leaking, and the site required regular cleansing and application of barrier cream. The director of nursing confirmed that the gastrointestinal consultation ordered for early February was not completed in a timely manner, as per the physician's orders. This oversight in following the care plan and physician's orders resulted in a deficiency in the facility's care for the resident.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for a resident diagnosed with anxiety disorder and post-traumatic stress disorder (PTSD). The clinical record review revealed that the facility did not identify the resident's PTSD triggers, which are essential to prevent re-traumatization. The resident's care plan, dated February 24, 2025, included a plan for PTSD but did not address the resident's actual condition, past experiences, or potential triggers. Interviews with the social worker confirmed that the care plan lacked these critical elements, indicating a deficiency in meeting professional standards of practice for trauma-informed care.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring and assessment for the continued use of psychotropic medication for one of the six residents reviewed, identified as Resident R19. The facility's policy on psychotropic medications mandates that as-needed (PRN) psychotropic medications are limited to a fourteen-day period unless a documented rationale and specific duration for extended use are provided by the prescriber. However, a clinical record review revealed that Resident R19 had a physician's order for Hydroxyzine HCL, an antihistamine used for anxiety, without documentation indicating a limited fourteen-day use or a rationale for its continued use beyond this period. Resident R19, who was cognitively intact, had diagnoses including seizure disorder and depression, and was receiving antidepressant and hypnotic medications. A psychiatrist's progress note indicated that the resident had dementia, insomnia, and anxiety, but reported feeling sad due to missing family rather than anxious. An interview with a registered nurse confirmed the absence of documentation for the limited use or extended rationale for Hydroxyzine HCL, highlighting a failure in adhering to the facility's policy on psychotropic medication management.
Inefficient Kitchen Equipment and Pest Access
Penalty
Summary
Essential food service equipment and mechanical devices in the main kitchen were found to be operating inefficiently and ineffectively. Observations revealed that the three-compartment sink used for sanitizing pots, pans, utensils, trays, and cooking equipment was not holding water and sanitizing solution properly. The water and chemical concentration were not at the recommended levels due to a leaking piping mechanism underneath the sinks. An interview with the Director of Dietary Services confirmed the absence of a commercial sink drain and stopper necessary for effective sanitization. Additionally, the metal doors leading from the main kitchen to the loading and receiving dock were not sealing completely, leaving a one-inch open space at the threshold due to a missing mechanical door sweep. This gap allowed easy access for pests and rodents. Observations in the dry food storage area revealed rodent droppings on the floor beneath the large metal shelving used for food storage.
Failure to Update Care Plan for Tuberculosis Diagnosis
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident R1, to reflect changes in care needs following a new tuberculosis diagnosis. The comprehensive care plan, which should have been revised by the interdisciplinary team after each assessment, did not include any interventions or specific care plans addressing the tuberculosis diagnosis. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan had not been updated to include special interventions related to care and isolation requirements. Resident R1 was admitted to the facility in late December 2024, and a review of their Minimum Data Set indicated that the Brief Interview for Mental Status was not recorded, suggesting severe cognitive impairment. In early January 2025, the facility was notified by a local hospital that Resident R1's tuberculosis test returned positive, prompting the facility to isolate the resident and notify relevant parties. However, the care plan dated December 30, 2024, did not reflect these significant changes in the resident's health status.
Plan Of Correction
1. Resident R1 care plan was updated to reflect active Tuberculosis diagnosis. 2. An audit of new diagnosis related to infectious disease will be completed going back 30 days to ensure appropriate care plans exist. 3. Professional nursing staff will be re-educated on updating care plans to reflect any new diagnosis obtained during their stay. 4. The DON/designee will complete random audits on care plans being updated weekly for four weeks and monthly for three months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations.
Failure to Report Tuberculosis Case to State Health Department
Penalty
Summary
The facility failed to report a case of tuberculosis (TB) to the Pennsylvania Department of Health (DOH) through the state Event Reporting System, as required by regulation. This deficiency was identified during a review of clinical files, facility documentation, and staff interviews. The Director of Nursing confirmed that a resident had tested positive for TB, and while the facility collaborated with the local county to report the case and implement recommended measures, they did not notify the DOH state survey agency. The Nursing Home Administrator also confirmed this failure to report the TB infection as required by the regulation.
Plan Of Correction
1. Employee E2 submitted reportable to Department of Health. 2. Facility will review incident reports and any new infection diagnosis for past 30 days to identify any missed reportable. 3. Director of Nursing will be re-educated on event reporting requirements. 4. The DON/designee will complete random audit to ensure all reportable events have been submitted to DOH reportable system weekly for four weeks and monthly for three months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident who was readmitted with a diagnosis of a replaced dislodged DOB tube, aspiration pneumonitis, and respiratory failure. The resident had specific physician's orders for Metoprolol tartrate and Midodrine, with parameters for administration based on blood pressure and heart rate. On August 17, 2024, the nurse responsible administered Midodrine despite the resident's blood pressure being 132/74, which was above the threshold to hold the medication as per the physician's order. Additionally, on August 18, 2024, the nursing staff documented holding Midodrine at 9:00 a.m. when the resident's blood pressure was 109/49, which was not in accordance with the physician's orders that required the medication to be held only if the systolic blood pressure was greater than 130. These actions were not aligned with the facility's policy on administering medications, which mandates that medications and treatments be administered in accordance with the physician's orders and documented accurately.
Failure to Complete STAT Doppler Study
Penalty
Summary
The facility failed to ensure that a doppler study was completed as ordered by the physician for a resident. The resident was readmitted to the nursing facility with a diagnosis of replaced dislodged DOB tube, aspiration pneumonitis, and respiratory failure. A nurse practitioner's progress note indicated that the resident was ordered a doppler study of the left arm due to swelling and pain. However, there was no doppler study completed and available for review. A STAT doppler study was ordered for the resident at 12:30 p.m. on August 23, 2024, due to acute pain and swelling of the left arm. An interview with the director of nursing revealed that STAT means emergency and the facility would complete the study within four hours of the order. Despite this, there was no documentation indicating that the STAT doppler study was available for review on August 23 or 24, 2024. The resident was admitted to the hospital for hypotension and gastrointestinal bleeding on August 24, 2024.
Failure to Document Blood Pressure and Medication Administration
Penalty
Summary
The facility failed to ensure complete documentation related to blood pressure monitoring and medication administration for one resident. The resident, who was readmitted to the facility with a diagnosis of a replaced dislodged DOB tube, aspiration pneumonitis, and respiratory failure, had specific physician orders for Metoprolol tartrate and Midodrine. These medications required monitoring of blood pressure and heart rate, with instructions to hold the medication if certain parameters were not met. On August 17, 2024, the nurse did not record the blood pressure or the administration of Metoprolol tartrate as per the physician's orders. Additionally, on August 19, 2024, the resident's blood pressure was recorded at 138/65, but the nurse failed to document that Midodrine was held in accordance with the physician's orders. This lack of documentation and adherence to the prescribed medication administration protocol led to the deficiency identified by the surveyors.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for five out of six residents reviewed. This deficiency was identified through clinical record reviews and staff interviews. The residents involved were transferred to local hospitals due to various medical emergencies, such as abnormal vital signs, respiratory distress, and other acute conditions. Despite these transfers, there was no documentation available to confirm that the Ombudsman was informed of these actions. The specific cases included a resident with abnormal vital signs and another with respiratory distress, both of whom were transferred to hospitals and subsequently discharged from the facility. Other residents experienced conditions such as swelling, vomiting, and abdominal pain, leading to their emergency transfers and eventual discharges. The Nursing Home Administrator confirmed the lack of documentation regarding the notification to the Ombudsman, which was a requirement under the applicable state codes.
Failure to Provide Consistent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatments and services to promote healing for a resident with pressure ulcers. The resident, who was admitted with multiple unstageable pressure ulcers and moisture-associated skin damage, required total assistance for all activities of daily living. Despite having a care plan in place, the facility did not consistently provide the prescribed wound treatments. Documentation revealed that treatments were not administered on several occasions, including specific dates in June, July, and August 2024. The resident's condition included diagnoses such as neurogenic bladder, paraplegia, Parkinson's Disease, spinal cord injury, and muscle weakness. The resident was cognitively intact with a BIMS score of 15. Upon readmission from the hospital, the resident had multiple stage 4 wounds, and the facility's Treatment Administration Records (TARs) indicated lapses in the application of prescribed treatments like calcium alginate, calmoseptine, medihoney, and Dakins solution. These treatments were either not provided or not documented as provided on several specified dates. Additionally, there was a grievance regarding the improper use of a specialty mattress ordered for the resident. The grievance noted that the resident was not placed correctly on the mattress, and staff were turning off the mattress during care. Although education on proper use was reportedly provided, there were no supporting documents available to verify this. Interviews with the Director of Nursing and the Director of Quality Experience confirmed the lapses in treatment and the issues with the specialty mattress.
Failure to Provide Timely Continence Care
Penalty
Summary
The facility failed to provide timely continence care for a resident, identified as Resident R1, who was admitted with multiple diagnoses including neurogenic bladder, paraplegia, Parkinson's Disease, spinal cord injury, and muscle weakness. The resident was cognitively intact with a BIMS score of 15 and was dependent on staff for toileting, being always incontinent of bowel and bladder. The care plan required incontinence care every two to three hours and as needed, with specific instructions to use barrier cream after each episode of incontinence and to provide daily catheter care. On July 23, 2024, a practitioner noted that Resident R1 was upset and frustrated due to not receiving care in the morning, as reported in a grievance filed by the resident. The grievance investigation revealed that a nurse aide claimed the resident refused care, but there was no documentation to support this claim. Another grievance filed on July 25, 2024, detailed an incident on July 24, 2024, where the resident's family member repeatedly requested assistance for the resident, who had a bowel movement. Despite multiple requests to various staff members, the resident was not cleaned until 3:45 p.m., and later that evening, the family member again found feces on the resident's urinary catheter, which was not addressed until 9:00 p.m. The Director of Quality Experience, Employee E5, acknowledged the delay in providing continence care and the lack of documentation for refusals of care. The investigation into the grievances showed that there were no supporting documents or staff education records available for review, and verbal education was provided without written statements from staff. The facility's failure to provide timely continence care and proper documentation led to the deficiency noted in the report.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to ensure that water temperatures in resident bathroom hand sinks and showers were maintained at a safe temperature for two of two nursing units observed. This failure placed residents at risk for serious injury from burns. Observations revealed that the water temperatures in the hand sinks and showers exceeded the safe limit, with temperatures recorded as high as 124 degrees Fahrenheit in some areas. The facility's policy stated that water temperatures should not exceed 100 degrees Fahrenheit, or the maximum allowable temperature per state regulation, but this was not adhered to. Maintenance staff were responsible for checking thermostats and temperature controls and recording these checks in a maintenance log. However, there were no documented temperatures during weekends, and several dates in April 2024 had no recorded temperatures. Interviews with staff revealed that they were unaware of the correct water temperature limits and did not have thermometers available to test the water temperature. Staff were using their hands to test the water temperature, which is not a reliable method to ensure safety. The Director of Maintenance confirmed that the water temperatures were too high and should be between 98 degrees Fahrenheit and 110 degrees Fahrenheit. The facility's mechanical contractors were on site to address a leak in the domestic water storage tank, which may have contributed to the temperature issues. Despite this, the facility failed to maintain safe water temperatures, leading to an Immediate Jeopardy situation for the residents' safety. Staff interviews further confirmed the lack of proper training and equipment to monitor and control water temperatures effectively.
Removal Plan
- The facility immediately suspended showers.
- The maintenance supervisor adjusted the mixing valve and began monitoring.
- Any residents who received a shower has been assessed by nursing staff to ensure no injuries have occurred.
- The facility mechanical contractors were on site and completed repairs to the hot water holding tanks.
- The facility water policy on water temperatures and showering/bathing has been updated to include staff ensuring the water temperature is within acceptable range and to not give shower/bath.
- Staff were immediately educated includes teaching staff how to properly test the water prior to giving the shower, and notify maintenance when temps are above the 110 requirement.
- Thermometers have been placed in each shower room.
- Staff in servicing has begun and will continue until all nursing staff have been educated. The staff will be in serviced either in person or over the phone. Our system tracks individual signs offs of the notifications, followed by an in person/phone in-service.
- The facility will continue random temperatures monitors every shift through nursing supervisor, the maintenance supervisor will also complete temperature logs daily in the AM and again at the maintenance shift.
- If the Maintenance director cannot be reached the Administrator will be notified if temperatures are found over 110.
- Both logs will be summarized and reported to QAPI (Quality Assurance Program Improvement), with any trends and effective interventions.
Failure to Follow Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that pressure ulcer prevention measures were followed as ordered by the physician for a resident with a history of impaired skin integrity. The resident, who had a past medical history of cerebral infarction, anoxic brain damage, persistent vegetative state, anemia, long-term anticoagulant use, gastrostomy status, and ventilator status, had physician orders to wear prevalon boots at all times except for hygiene or skin checks and to offload heels with pillows while in bed. However, observations and progress notes revealed that these measures were not consistently followed, leading to the re-opening of a stage 3 pressure ulcer on the resident's right heel. The wound care nurse noted that the right heel wound re-opened because the heel boot was not always on, and the pillow was not always propped up under the knee as required. Further review of progress notes indicated that there was no improvement in the stage 3 right heel wound, and the resident's booties were not on during a nurse practitioner's visit. The wound care nurse confirmed during an interview that the right heel wound re-opened due to inconsistent application of the heel boot and pillow. The facility's failure to adhere to the prescribed pressure ulcer prevention measures resulted in the resident's pressure ulcer not improving and re-opening, demonstrating a deficiency in the facility's care practices.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care services consistent with professional standards of practice for three residents. Resident R38, who was admitted with a diagnosis of Acute and Chronic Respiratory Failure with Hypoxia and had a tracheostomy, did not have an ambu bag and emergency kit set up at the bedside. Additionally, two other residents, R41 and R390, had ambu bags that were open to the air and not stored in a clean set-up bag as required by the facility's policy. These deficiencies were confirmed by the Clinical Coordinator, who acknowledged the absence of the ambu bag and emergency kit for Resident R38 and the improper storage of the ambu bags for Residents R41 and R390. Further observations revealed that Resident R85's aerosol tubing was not dated, which is against the facility's policy that requires tubing to be changed monthly or as needed. This was confirmed by the Respiratory Therapist, who acknowledged that the tubing should have been labeled and changed accordingly. These findings indicate a failure to adhere to the facility's policies on respiratory care equipment maintenance and storage, potentially compromising the residents' respiratory care.
Failure to Manage Hot Water Temperatures
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility's hot water temperatures, resulting in an Immediate Jeopardy situation. During an initial tour of the facility, it was observed that water temperatures in resident bathroom sinks and shower rooms were above 110 degrees Fahrenheit on both nursing units. This was confirmed by the Director of Maintenance, who acknowledged that the elevated temperatures had not been identified prior to the tour. This oversight placed residents at risk for serious injury from burns. The job descriptions of both the NHA and DON emphasize their responsibility to ensure the highest degree of quality care in accordance with federal, state, and local regulations. However, their failure to monitor and control water temperatures as required led to a significant safety hazard. The deficiency was identified based on observations, facility documentation, and staff interviews, highlighting a critical lapse in the facility's management and operational oversight.
Failure to Maintain Accurate Resident Records
Penalty
Summary
The facility failed to ensure that resident records were accurately documented for one of the 27 residents reviewed. Specifically, Resident R69, a [AGE] year old female with a complex medical history including cerebral infarction, anoxic brain damage, and ventilator status, had an erroneous pulmonary progress note entered into her clinical record. The progress note, dated March 14, 2024, was completed by a physician who was not the resident's assigned physician and contained information about a different patient, a [AGE] year old male with a C4-5 fracture and pneumonia, which was not relevant to Resident R69's condition or history. The erroneous entry was confirmed by the Nursing Home Administrator and the Director of Nursing, who acknowledged that the progress note did not pertain to Resident R69. This discrepancy indicates a failure in maintaining accurate and resident-specific medical records, as required by accepted professional standards. The facility's failure to safeguard resident-identifiable information and ensure accurate documentation was cited under 28 Pa Code 211.5(f)(ii)(iv) and 28 Pa Code 211.12(d)(1) and (c) for medical and nursing services, respectively.
Infection Control Deficiencies During Medication Administration and Wound Care
Penalty
Summary
The facility failed to maintain effective infection control and prevention practices during medication administration for two residents. During an observation, a licensed nurse was seen with an uncapped and pre-filled insulin syringe on top of the medication cart, which was then carried to a resident's room and placed on the bedside table. The same nurse attempted to open a new bottle of Lacosamide oral solution with her keys and struggled to collect urine from a resident's Foley catheter, during which her personal cell phone fell multiple times, contaminating the cup and Foley catheter she was handling. These actions were in direct violation of the facility's policy on administering medications safely and timely. Additionally, another licensed nurse was observed administering wound care to a resident with a diagnosis of traumatic hemorrhage of the cerebrum and type 2 diabetes mellitus. The nurse used the same gauze piece to cleanse the inside of the wound after cleaning the peripheral area, which is a breach of infection control protocols. This was confirmed by the nurse during an interview at the time of the observation. These deficiencies highlight significant lapses in infection control practices during both medication administration and wound care treatment.
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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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