Belvedere Center, Genesis Healthcare, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Chester, Pennsylvania.
- Location
- 2507 Chestnut Street, Chester, Pennsylvania 19013
- CMS Provider Number
- 395595
- Inspections on file
- 23
- Latest survey
- August 25, 2025
- Citations (last 12 mo.)
- 58
Citation history
Health deficiencies cited at Belvedere Center, Genesis Healthcare, The during CMS and state inspections, most recent first.
A resident with dementia and other health issues developed a Stage 3 pressure ulcer due to the facility's failure to monitor skin condition and follow wound treatment orders. Despite being at risk, the resident's wound was not treated as prescribed, leading to deterioration and hospital transfer for osteomyelitis treatment.
A facility failed to maintain the dignity of a resident by displaying a 'FALL RISK' sign on their door without consent. The resident, who has moderate cognitive impairment and communication difficulties due to a brain hemorrhage, had the sign displayed for several days. The NHA confirmed the lack of consent, acknowledging the failure to respect the resident's dignity.
A facility failed to ensure accurate documentation of a resident's advanced directives. The resident, with severe cognitive impairment and multiple health issues, had conflicting records: a care plan indicating Full Code and physician orders stating DNR, DNI, and DNH. No explanation for this discrepancy was found in the progress notes, as confirmed by the DON.
A facility failed to develop a baseline care plan for a resident readmitted with acute diastolic congestive heart failure and requiring continuous oxygen therapy. Despite physician orders for specific oxygen management, the care plan lacked necessary details for the resident's oxygen needs. This was confirmed through clinical record review and a DON interview.
A facility failed to develop a comprehensive care plan for a resident identified as an elopement risk. Despite assessments indicating the risk, the care plan lacked measures to address it. This deficiency was confirmed with the DON.
A resident with mild cognitive impairment and identified as an elopement risk left a medical appointment unsupervised. Despite a care plan involving the resident's Power of Attorney for escorting to appointments, the resident left the facility before the Power of Attorney arrived, indicating inadequate supervision.
A resident with an indwelling catheter did not receive documented catheter care after the physician's order was discontinued. Despite the order being discontinued, the resident still had the catheter, and there was no evidence of care provided. The DON confirmed the lack of documentation and care, violating clinical record and resident care policies.
A resident with dementia and a left femur fracture experienced two unwitnessed falls with no observed injuries. Later, an x-ray revealed a fracture in the resident's left foot, which the facility failed to investigate, assuming it was pre-existing from the hospital. The Nursing Home Administrator confirmed no investigation was conducted, and no documentation supported the fracture's origin prior to admission.
The facility failed to follow a physician's order for vital signs monitoring and did not notify the physician of an x-ray result in a timely manner for a resident with dementia, a femur fracture, and pneumonia. The resident's vital signs were checked only once daily instead of twice, and the physician was not promptly informed of a foot fracture revealed by an x-ray.
Failure to Monitor Skin and Follow Treatment Orders Leads to Wound Deterioration
Penalty
Summary
The facility failed to monitor a resident's skin condition and follow the wound physician's treatment orders, resulting in harm to the resident. The resident, who had dementia, a urinary tract infection, and peripheral vascular disease, was admitted without any pressure ulcers but was at risk for developing them. Despite weekly skin assessments, a new Stage 3 pressure ulcer was discovered on the resident's sacrum, indicating a failure in early detection and intervention. The wound physician's orders to treat the sacral wound daily were not followed, as the treatment was administered every other day instead. This non-compliance with the physician's orders led to the wound's deterioration, as evidenced by the wound consult reports showing the wound's progression from Stage 3 to unstageable with increased slough and eschar. The wound nurse confirmed that the treatment orders were not followed, contributing to the resident's worsening condition. The resident's condition deteriorated further, with the wound becoming malodorous and painful, leading to a hospital transfer where early coccygeal osteomyelitis was diagnosed. The wound required surgical debridement and IV antibiotics. The facility's failure to ensure proper skin monitoring and adherence to treatment orders resulted in significant harm to the resident, including wound deterioration and unnecessary pain.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident 80, by displaying a sign on the resident's door indicating 'FALL RISK' without obtaining consent from the resident or their Power of Attorney (POA). Resident 80, who has a BIMS score of 8 indicating moderate cognitive impairment, also has difficulty understanding and communicating with others due to an active diagnosis of Other Nontraumatic Intracerebral Hemorrhage. Observations on three consecutive days revealed that the sign remained on the resident's door. The Nursing Home Administrator confirmed that the facility did not have consent to display the sign, acknowledging the failure to respect the resident's dignity.
Inconsistent Advanced Directives Documentation
Penalty
Summary
The facility failed to ensure that the advanced directives for a resident were accurately reflected in the resident's records. The resident, who was admitted with multiple diagnoses including chronic kidney disease, prostate cancer, and severe cognitive impairment, had conflicting documentation regarding their advanced directives. A care plan dated January 24, 2023, indicated the resident had an advanced directive of Full Code, while a subsequent care plan dated April 12, 2024, noted the resident was admitted to hospice care with a goal related to end-of-life acceptance. However, the active physician orders from April 10, 2024, indicated the resident's advanced directive was Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Do Not Hospitalize (DNH). There was no documentation in the progress notes from April 10, 2024, through July 18, 2024, explaining the discrepancy between the physician's orders and the care plan. This inconsistency was confirmed during an interview with the Director of Nursing on July 18, 2024.
Failure to Develop Baseline Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was readmitted with acute diastolic congestive heart failure, hypertension, and an absence of the left leg above the knee. The resident required continuous oxygen therapy at 2L/min via nasal cannula, as documented in physician orders. These orders included monitoring pulse oxygen every shift to maintain oxygen saturation levels at or above 90%, cleaning the external filter on the oxygen concentrator, and changing the oxygen tube weekly with proper labeling. Despite these requirements, the resident's care plan did not include a baseline care plan for the oxygen therapy. This deficiency was identified during a review of the resident's clinical records and confirmed in an interview with the Director of Nursing.
Failure to Address Elopement Risk in Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented for a resident identified as being at risk for elopement. The clinical record review revealed that the resident, referred to as Resident 113, had an admission elopement assessment indicating a score of 6, which classified the resident as an elopement risk. A subsequent elopement assessment also indicated a score of 1, maintaining the resident's status as an elopement risk. Despite these assessments, the resident's care plan did not include any measures or strategies to address the risk of elopement. These findings were confirmed with the Director of Nursing during a discussion on July 18, 2024, at 10:05 a.m. The deficiency was noted under the regulations 28 Pa. Code 211.5(f) concerning clinical records and 28 Pa. Code 211.12(d)(1)(5) regarding nursing services.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as an elopement risk. The resident, who was admitted with diagnoses including altered mental status and schizophrenia, initially had no cognitive impairment but later showed mild cognitive impairment. Despite being identified as an elopement risk in assessments, the resident was allowed to attend a medical appointment without a staff escort, as per a transportation agreement signed earlier. The resident's Power of Attorney had agreed to escort the resident to medical appointments, but on the day of the incident, the resident left the vascular surgery center before the Power of Attorney arrived. On the day of the incident, the resident was scheduled for a vascular appointment at 10:30 a.m. The facility received a call at 11:00 a.m. from the surgery center, reporting that the resident had left the building after checking in. A witness statement from the transport driver confirmed seeing the resident walking down the street. This incident highlights the facility's failure to ensure adequate supervision and adherence to the care plan, which included the involvement of the resident's Power of Attorney for medical appointments.
Failure to Provide Catheter Care for a Resident
Penalty
Summary
The facility failed to provide necessary catheter care for a resident, identified as Resident 90, who had an indwelling catheter. According to the clinical record review, there was a physician's order dated January 16, 2024, for the resident to receive catheter care every day and night shift. This order was discontinued on April 17, 2024. However, an observation on July 15, 2024, revealed that the resident still had an indwelling catheter, and there was no documented evidence of catheter care being provided since the order was discontinued. An interview with the Director of Nursing on July 18, 2024, confirmed that Resident 90 had an indwelling catheter and that there was no documentation of catheter care since April 17, 2024. This lack of documentation and care was a violation of the facility's clinical record and resident care policies, as well as nursing services regulations.
Failure to Investigate Injury of Unknown Cause
Penalty
Summary
The facility failed to comprehensively investigate an injury of unknown cause for a resident diagnosed with dementia and a fracture of the left femur. The resident experienced two unwitnessed falls on December 22 and December 24, 2023, with no injuries observed at the time. However, on December 29, 2023, the resident's daughter-in-law requested an x-ray due to the resident's complaint of pain when the foot was massaged. The x-ray revealed an acute/subacute nondisplaced fracture of the distal left fifth metatarsal bone. Despite this finding, the facility did not investigate the origin of the fracture, assuming it was present from the hospital based on the family's report and the resident's reaction to touch. The Nursing Home Administrator confirmed that no investigation was conducted regarding the left foot fracture identified on December 29, 2023. The facility could not provide documentation indicating that the fracture occurred prior to the resident's admission. This lack of investigation into the injury of unknown origin constitutes a failure to ensure comprehensive care and safety for the resident.
Failure to Follow Physician's Orders and Timely Notify Physician
Penalty
Summary
The facility failed to follow a physician's order regarding vital signs monitoring and did not notify the physician of an x-ray result in a timely manner for a resident. The resident had a diagnosis of dementia, a fracture of the left femur, and pneumonia. An x-ray was ordered for the resident's left foot due to pain, revealing an acute/subacute nondisplaced fracture of the distal left fifth metatarsal bone. The radiology report was placed in the physician's book for review, but the physician was not notified immediately. The physician only became aware of the fracture during a follow-up visit several days later, leading to a delay in appropriate care instructions, such as non-weight bearing and specialist evaluation. Additionally, the facility did not adhere to a physician's order to check the resident's vital signs twice daily for pneumonia. The clinical records showed that vital signs were only checked once daily over several days, contrary to the physician's order. This was confirmed by the Assistant Director of Nursing, who acknowledged that the order was not followed as required.
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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