Bethlehem North Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Bethlehem, Pennsylvania.
- Location
- 2029 Westgate Drive, Bethlehem, Pennsylvania 18017
- CMS Provider Number
- 395527
- Inspections on file
- 18
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Bethlehem North Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with polyneuropathy and dementia, dependent on staff for daily activities, was found with the call bell out of reach on multiple occasions. The care plan required the call bell to be accessible to prevent falls, but it was observed on the floor next to the bed. The ADON confirmed the call bell should have been within reach.
The facility failed to notify the responsible parties of three residents who experienced significant weight loss, as required by their policies. A resident with sarcopenia and dementia lost 10.8% of their weight, another with anemia and anxiety lost 11.8%, and a third with a traumatic brain injury and dysphagia lost 5.0%. The facility's administrator confirmed the lack of evidence for notifying the residents' representatives.
The facility failed to maintain adequate grooming and hygiene for three residents dependent on staff for ADLs. A resident with muscle weakness had long, dirty nails despite preferring them short. Another resident with dementia and dermatitis had long, jagged nails with a dark substance underneath, and a third resident with dementia and anxiety also had long, dirty nails. The ADON confirmed that nail care should have been provided during bathing and as needed.
A resident with a history of stroke and depression did not receive the necessary orthotic device to prevent a decline in range of motion. Despite a physician's order and an occupational therapy discharge assessment recommending a hand grip, staff failed to update the clinical record and assist the resident with the device. Observations confirmed the absence of the device, and the resident reported a lack of staff assistance.
A facility failed to implement smoking safety measures for a resident with depression and anxiety. The facility's policy requires smoking supplies to be stored by staff at the nurses' station, but the resident kept them in a personal bag on his bed. Interviews with the DON and ADON confirmed the supplies should have been stored according to policy.
The facility failed to monitor and address significant weight loss for two residents at risk for nutritional problems. One resident, with traumatic brain injury and dysphagia, lost 12 pounds over a short period, and the RD was not notified until much later. Another resident lost 24.2 pounds, and the weight loss was not addressed promptly. The Administrator confirmed the lack of timely notification and intervention.
A resident with a history of stroke and depression did not receive the required adaptive eating equipment, specifically a curved spoon, as outlined in her care plan. Despite the care plan's directive and the resident's meal tray ticket indicating the need for a curved spoon, observations revealed that she was consistently given a regular spoon during meals.
A dietary employee failed to maintain sanitary conditions during food service by not changing gloves or performing hand hygiene after leaving the tray line, wiping gloves on clothing, and handling cooked chicken with the same gloves.
The facility failed to notify residents and their representatives of appeal rights and Ombudsman information upon hospital transfer. Five residents were transferred due to a change in condition, but there was no documented evidence that they or their representatives received the required notifications.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call bell was accessible for a resident, identified as Resident 104, who was part of a sample of 39 residents. Resident 104 had medical diagnoses including polyneuropathy and dementia, and was dependent on staff for activities of daily living such as toileting, dressing, and personal hygiene. The care plan for Resident 104 indicated a risk for falls and included an intervention for staff to keep commonly used articles within easy reach and to reinforce the need for the resident to call for assistance. However, on March 5, 2025, the resident was observed in bed with the call bell on the floor and out of reach at three different times: 11:16 a.m., 12:19 p.m., and 2:40 p.m. The Assistant Director of Nursing confirmed that the call bell should have been placed within the resident's reach.
Failure to Notify Representatives of Significant Weight Loss
Penalty
Summary
The facility failed to notify the responsible parties of three residents who experienced significant weight loss, as required by their policies. The facility's policy on 'Weights and Heights' and 'Change in Condition: Notification of' mandates immediate notification to a resident's representative in the event of a significant change in condition, such as weight loss. However, clinical record reviews revealed that the facility did not adhere to these policies for three residents. Resident 44, diagnosed with sarcopenia and dementia, experienced a 10.8% weight loss over a month, with no evidence of notification to their representative. Resident 46, with anemia and anxiety, lost 11.8% of their weight in a month, again without notification. Resident 164, who had a traumatic brain injury and dysphagia, lost 5.0% of their weight in a short period, and there was no evidence of notification. The facility administrator confirmed the lack of evidence for notifying the residents' representatives about these significant weight losses.
Failure to Provide Adequate Grooming and Hygiene
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for three residents who were dependent on staff for activities of daily living (ADLs). Resident 1, diagnosed with muscle weakness, required assistance with ADLs and preferred her nails to be kept short. However, observations on consecutive days revealed her nails were long and dirty, and she confirmed that staff had not offered assistance with nail care. There was no evidence of her refusing such care. Resident 99, who had dementia and dermatitis, was also dependent on staff for ADLs. Observations showed her fingernails were long, jagged, and dirty, with a dark substance underneath. She indicated a preference for her nails to be cut, yet no assistance was provided. Similarly, Resident 183, with unspecified dementia and anxiety, was observed with long, jagged, and dirty nails. Despite her dependence on staff for ADLs and her expressed dislike for long nails, no assistance was offered. The Assistant Director of Nursing confirmed that nail care should have been provided during bathing and as needed.
Failure to Implement Orthotic Device for Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent a decline in range of motion for Resident 159, who had a history of stroke and depression. The resident's care plan indicated self-care deficits and required staff assistance for activities of daily living. A physician's order dated December 27, 2024, instructed staff to apply a soft hand splint to the resident's right hand during the day shift. However, the clinical record was not updated to reflect the correct orthotic device as per the occupational therapy discharge assessment, which recommended a right palm grip to be placed during morning care. Observations on March 4 and 5, 2025, revealed that Resident 159's right hand was contracted, and no orthotic device was in place. The resident reported that staff often did not assist with the placement of the orthotic device, and she had not refused assistance. The Assistant Director of Nursing confirmed that the order for the new hand grip was not implemented according to the therapy discharge summary. There were no documented refusals from the resident regarding the use of the orthotic device.
Failure to Implement Smoking Safety Measures
Penalty
Summary
The facility failed to implement safety measures related to smoking for a resident who smokes. The facility's smoking policy, last reviewed in November 2024, requires that smoking supplies, including cigarettes and lighters, be labeled with the resident's name, room number, and bed number, and be maintained by staff in a suitable cabinet at the nurses' station. However, a clinical record review revealed that the resident, who has diagnoses of depression and anxiety, was independent for smoking, and staff were to educate and monitor compliance with the smoking policy. On March 4, 2025, the resident was observed with his smoking supplies in his personal bag on his bed, contrary to the policy. Interviews with the Director of Nursing and the Assistant Director of Nursing confirmed that the supplies should have been kept behind the nurses' station, and the resident's possession of the supplies was acknowledged as a deviation from the policy.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and assess weight loss for two residents at risk for nutritional problems. Resident 164, diagnosed with traumatic brain injury and dysphagia, experienced a significant weight loss of 12 pounds (5.2%) between December 19 and December 24, 2024. Despite the facility's policy requiring notification of the registered dietitian (RD) for significant weight changes, there was no evidence that the RD was informed of this weight loss. The RD did not address the issue until January 30, 2025, by which time the resident's weight had fluctuated significantly, indicating continued weight loss. The resident's nutritional supplements were discontinued without confirmation of weight gain, and the RD was not notified of the ongoing weight loss. Similarly, Resident 46, who had a history of significant weight loss and was at risk for nutritional problems, lost 24.2 pounds (11.8%) between December 3, 2024, and January 3, 2025. The facility's care plan required staff to monitor changes in nutritional status, but there was no evidence that the RD was notified of this significant weight loss. The weight loss was not addressed until February 10, 2025. In an interview, the Administrator confirmed the lack of evidence that the RD was notified or that the weight loss was addressed in a timely manner.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive equipment to a resident, identified as Resident 159, who required it due to medical conditions including stroke and depression. The resident's care plan specified the need for a curved right spoon to mitigate nutrition risks. However, during observations on March 4 and March 5, 2025, the resident was repeatedly provided with a regular spoon instead of the required curved spoon during meal times. The resident confirmed that she often did not receive the curved spoon as indicated on her meal tray ticket.
Failure to Maintain Sanitary Conditions During Food Service
Penalty
Summary
The facility failed to maintain sanitary conditions during food service in the kitchen. During an observation of the tray line service, a dietary employee was seen wearing gloves while assembling resident meals. The employee left the tray line to obtain plates, pushing a rolling cart, and did not change gloves or perform hand hygiene upon returning. The employee continued to assemble meals with the same gloves and was observed wiping the gloves on her clothing twice without changing them or performing hand hygiene. Additionally, the employee picked up cooked chicken from a steam table pan with the same gloves and placed it onto resident meal trays six times without changing gloves or performing hand hygiene throughout the observation period.
Failure to Notify Residents of Appeal Rights and Ombudsman Information
Penalty
Summary
The facility failed to provide timely notification to residents and their representatives regarding their appeal rights and Ombudsman information upon transfer to the hospital. This deficiency was identified for five residents who were transferred due to a change in condition. The clinical record reviews for Residents 14, 57, 101, 133, and 164 revealed that there was no documented evidence that these residents, their responsible parties, or legal representatives were informed in writing about their appeal rights and the Ombudsman when they were transferred to the hospital. Each of the five residents experienced a change in condition that necessitated their transfer to the hospital. However, the facility did not fulfill its obligation to provide the required notifications, which are crucial for ensuring that residents and their representatives are aware of their rights and the resources available to them during such transitions. The absence of documentation in the clinical records indicates a systemic issue in the facility's process for handling transfers and ensuring compliance with regulatory requirements.
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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