Brethren Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, Pennsylvania.
- Location
- 3001 Lititz Pike, Lancaster, Pennsylvania 17606
- CMS Provider Number
- 395328
- Inspections on file
- 20
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Brethren Village during CMS and state inspections, most recent first.
A resident had a PRN order for Ativan 0.5 mg for anxiety/restlessness and received multiple doses over the course of a month. Review of the MAR and clinical record showed repeated administration of the PRN anti-anxiety medication without any documented attempts at non-pharmacological interventions beforehand. In an interview, the NHA and DON confirmed that such non-pharmacological measures were not attempted prior to giving the PRN Ativan.
A resident with a PRN order for Oxycodone 5 mg every 6 hours for severe pain was given the medication multiple times when pain levels were documented as zero. Facility policy defined the 0–10 pain scale and specified that severe pain corresponds to scores of 8–10, but review of the MAR showed Oxycodone was administered despite no reported pain. In an interview, the NHA and DON confirmed that the pain scale parameters in the physician’s PRN order were not followed.
A resident with hemiplegia, contractures, and a history of falls, who required a two-person assist for transfers, was transferred by a CNA alone using a bear hug technique. This improper transfer resulted in the resident sustaining a subcapital humeral fracture, as confirmed by x-ray. Facility investigation substantiated that the care plan was not followed, leading to actual harm.
A resident with a spinal cord injury and diabetes suffered harm due to neglect in wound care at a facility. The resident's pressure ulcer worsened after the facility failed to renew a treatment order and did not ensure the availability of necessary medication. This led to the wound becoming infected and requiring hospitalization for surgical intervention.
A resident with a history of pressure ulcers experienced wound deterioration and infection due to inconsistent treatment and lack of communication in an LTC facility. Despite being at risk, the resident's wound care was missed on several occasions, and a critical medication was delayed, leading to a Stage 4 ulcer and hospitalization for surgical intervention.
A resident's wound care was not administered as per physician's orders on multiple occasions, and the required medication was delayed. The LPN did not notify the physician or follow up on the medication, leading to a deviation from the prescribed treatment.
Failure to Attempt Non-Pharmacological Interventions Before PRN Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to administering a PRN anti-anxiety medication to a resident. Clinical record review showed that the resident had a physician’s order for Ativan 0.5 mg every four hours as needed for anxiety or restlessness and that the medication was administered multiple times throughout January 2026, including on January 1, 2, 3, 5, 6, 8, 9, 10, 11, 21, 22, 26, and 27. Review of the resident’s clinical record did not show any documentation that non-pharmacological interventions were attempted before giving the PRN Ativan on these dates. In an interview on January 30, 2026, at 10:50 a.m., the Nursing Home Administrator and Director of Nursing confirmed that no non-pharmacological interventions were attempted prior to the administration of the PRN Ativan, corroborating the lack of evidence in the clinical record.
Failure to Follow PRN Pain Medication Orders Based on Pain Scale
Penalty
Summary
The facility failed to follow a physician’s order for as-needed (PRN) pain medication for one resident when nursing staff administered Oxycodone 5 mg for pain levels documented as zero. Facility policy titled “Pain Observation/Evaluation,” revised January 2026, defined the 0–10 pain scale and specified that mild pain corresponds to 0–3, moderate to 4–7, and severe to 8–10. The resident had a physician’s order for Oxycodone 5 mg to be given every 6 hours as needed for severe pain. Review of the January Medication Administration Record showed that the resident received Oxycodone 5 mg every 6 hours as needed on multiple dates despite pain levels recorded as zero at the time of administration. In an interview, the Nursing Home Administrator and DON confirmed that the pain scale specified in the physician’s PRN pain medication order was not followed according to the order.
Failure to Follow Care Plan During Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis following a stroke, severe protein-calorie malnutrition, a history of falls, and contractures was not provided care according to their individualized care plan. The care plan and Kardex specified that the resident required an extensive two-person assist for transfers due to limited physical mobility and right-sided weakness. Despite these documented requirements, a certified nurse aide (CNA) transferred the resident alone using a bear hug technique, rather than with the assistance of a second staff member as required. As a result of this improper transfer, the resident reported hearing a pop in the right shoulder and experienced pain and tenderness. An immediate x-ray confirmed a subcapital humeral fracture. Facility investigation, including staff and resident interviews, substantiated that the CNA did not follow the care plan, leading to actual harm to the resident. The facility confirmed that the transfer was not performed according to the resident's care plan, resulting in the injury.
Neglect in Wound Care Leads to Resident Harm
Penalty
Summary
Brethren Village was found to be non-compliant with the requirement to ensure residents are free from neglect, as evidenced by the inadequate wound care provided to a resident with a thoracic spinal cord injury and diabetes. The resident was admitted with an improving Stage 3 pressure ulcer on the coccyx, which required specific wound treatment. However, the facility failed to consistently apply the prescribed treatment, leading to the deterioration of the wound. The facility's records showed that the wound treatment order expired and was not renewed, resulting in missed treatments on several days. Additionally, when a new treatment was ordered, the necessary medication was not available due to a computer entry error, and the staff did not follow up with the pharmacy or notify the physician about the unavailability of the medication. This lack of action led to the wound becoming unstageable, with increased slough and infection, as confirmed by a wound culture. The resident's condition worsened, requiring hospitalization for surgical debridement and intravenous antibiotics. The facility's failure to provide consistent and correct wound care resulted in actual harm to the resident, including unnecessary pain and hospitalization. The deficiency was substantiated by the facility's own investigation, which confirmed neglect by a staff member.
Plan Of Correction
Preparation and submission of the plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Santyl was received January 27th and treatment applied appropriately on that date forward. Education and corrective action provided to team member involved January 27, 2025. Team member terminated 2/6/2025. Team member who did not transcribe medication properly educated and corrective action January 31, 2025. Audits was done on past month of treatments to identify any trends and patterns. Completed February 6, 2025. Licensed staff educated on notification of physician's residents and resident representative if treatment is not available. Completed by February 8, 2025. Order set for wounds added to EMR, education provided to licensed team members on use of order set and documentation. Completed by February 8, 2025. Audits on wound order set began February 13, 2025 x 4 weeks. Wound Policy and procedure was reviewed, updated and wound team educated. Completed by January 30, 2025.
Inadequate Wound Care Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide consistent and appropriate treatment for an unstageable pressure ulcer for Resident CL1, resulting in wound deterioration, infection, and hospitalization. Resident CL1 was admitted with an improving Stage 3 pressure ulcer and was identified as 'At Risk' for developing pressure ulcers. The care plan included interventions such as turning and positioning, adequate nutrition, and wound treatment as ordered. However, there were missed wound care treatments on specific dates, and the attending physician was not notified of these omissions. The wound deteriorated, becoming unstageable with increased slough and drainage, and a new treatment was recommended. Despite a physician's order for Santyl, the medication was not delivered promptly, and alternative treatments were used without notifying the physician or supervisor. This lack of communication and follow-up led to further deterioration of the wound, which developed tunneling and purulent discharge, indicating infection. A wound culture confirmed the presence of multiple organisms, and the resident was placed on antibiotics and scheduled for a wound clinic consult. The wound was assessed as a Stage 4 pressure ulcer with necrotic tissue and exposed bone, requiring operative debridement and IV antibiotics. The resident was subsequently hospitalized for surgical intervention, highlighting the facility's failure to ensure consistent and appropriate wound care, resulting in actual harm to the resident.
Plan Of Correction
Preparation and submission of the plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Santyl was received January 27th and treatment applied appropriately on that date forward. Education and corrective action provided to team member involved January 27, 2025. Team member terminated 2/6/2025. Team member who did not transcribe medication properly educated and corrective action January 31, 2025. Audits was done on past month of treatments to identify any trends and patterns. Completed February 6, 2025. Licensed staff educated on notification of physician's residents and resident representative if treatment is not available. Completed by February 8, 2025. Order set for wounds added to EMR, education provided to licensed team members on use of order set and documentation. Completed by February 8, 2025. Audits on wound order set began February 13, 2025 x 4 weeks. All findings to be reported to Quality Assurance Committee. Wound Policy and procedure was reviewed, updated and wound team educated. Completed by January 30, 2025. Education and corrective action provided to Wound Care Certified nurse. (Wound team leader). Wound Care nurse terminated February 5, 2025.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that staff met professional standards for a licensed nurse in following a physician's wound care order for a resident identified as CL1. The resident had an unstageable coccyx wound that required specific treatment as per a physician's order, which included cleansing with normal saline, applying Medihoney and Calcium Alginate, and covering with a dressing daily. However, the clinical records revealed that the wound was not treated on three specific days, and there was no documentation that the physician was notified of the missed treatments. Additionally, a new wound care order was issued, but the required Santyl medication was not delivered to the facility until four days later. During this period, the wound was treated with an alternative method not in accordance with the physician's order. The nurse responsible did not follow up with the pharmacy, inform the supervisor, or notify the physician about the unavailability of the medication and the deviation from the prescribed treatment. This failure to adhere to professional standards and facility policies was confirmed through staff interviews and a review of relevant records.
Plan Of Correction
Preparation and submission of the plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Santyl was received January 27th and treatment applied appropriately on that date forward. Education and corrective action provided to team member involved January 27, 2025. Team member terminated 2/6/2025. Audits was done on past month of treatments to identify any trends and patterns. Completed February 6, 2025. Licensed staff educated on notification of physician's residents and resident representative if treatment is not available. Completed by February 8, 2025. Order set for wounds added to EMR, education provided to licensed team members on use of order set and documentation. Completed by February 8, 2025. Audits on wound order set began February 13, 2025 x 4 weeks.
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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