Brookside Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Roslyn, Pennsylvania.
- Location
- 2630 Woodland Road, Roslyn, Pennsylvania 19001
- CMS Provider Number
- 395227
- Inspections on file
- 24
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Brookside Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Several residents did not receive planned menu items, specifically pumpkin pie, during a lunch meal, and no substitutions were provided. The Dietary Manager confirmed that the item was not served as indicated on the pre-approved menu.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as no soap in a hand wash sink, flies in dishwashing areas, and debris in clean adaptive cups. A cereal container was left open, and debris was found on the floor near juice and ice machines. Trash bags were stored on clean bowls, and ear buds were on a food prep surface. The wall molding was damaged, and debris was found near a clean pot shelf.
The facility failed to follow physician's orders for six residents, resulting in improper medication administration and care. Residents received medications outside prescribed parameters, and heel boots were not applied as ordered for residents at risk of skin breakdown. The administrator confirmed these deficiencies.
A resident with parkinsonism, depression, and muscle weakness was found to have an inaccessible call bell, contrary to their care plan which required it to be within reach due to their fall risk and limited mobility. The call bell was observed on the floor, out of reach, and the resident was unaware of its location.
The facility failed to provide a baseline care plan summary to two residents or their representatives within 48 hours of admission, as required by policy. The baseline care plans were developed, but there was no evidence that the summaries, which should include person-centered care instructions and initial goals, were provided. This was confirmed by the Administrator.
The facility failed to implement comprehensive care plans for three residents. A resident with muscle weakness and depression did not receive fortified mashed potatoes as per the care plan. Another resident with dementia and heart failure lacked interventions for psychotropic medication in their care plan. A third resident at risk for skin breakdown did not have heel boots applied as required. The Administrator and DON confirmed these deficiencies.
The facility failed to implement safety interventions for two residents at risk for falls and did not safely administer medications for another resident. One resident's bed was not kept in the lowest position, and another resident's medications were left unsupervised despite not being approved for self-administration.
A resident with dementia and adult failure to thrive experienced significant weight loss, but the facility did not follow its policy to retake the weight or notify the dietitian. The resident's weight change was not assessed until a month later, as confirmed by the Administrator.
A facility failed to assess and treat an external urinary catheter for a resident with diagnoses including neoplasm of cranial nerves and pulmonary fibrosis. The facility's policy required a physician's order for catheter use and daily assessment and change of the catheter. However, the catheter was not changed until a later date, and there was no documentation of a physician's order or skin assessment until then. The Nursing Home Administrator confirmed these actions were expected but not documented.
A resident with anxiety and depression did not receive prescribed doses of Lorazepam due to unavailability of the medication. The resident reported missed doses, and the Nursing Home Administrator confirmed the failure to administer the medication as ordered, noting that the nursing supervisor did not obtain it from the emergency supply.
Failure to Serve Menu Items as Planned
Penalty
Summary
The facility failed to follow its pre-approved menus as required, resulting in residents not receiving menu items as planned. Multiple residents reported that menu items were frequently substituted without notification or were not received at all. On a specific lunch meal, the menu indicated that pumpkin pie should have been served, including a pureed version for those requiring texture modification. However, several residents did not receive the pumpkin pie or any substitution for it, as confirmed by review of meal tickets and direct observation. The Dietary Manager acknowledged that the pumpkin pie was not served as planned on the facility menu.
Sanitary Conditions Not Maintained in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey on October 29, 2024. The deficiencies included the absence of soap in the dispenser at a hand wash sink, the presence of flies in the dishwashing and tray line areas, and a tray of clean adaptive cups containing debris such as crumbs, paper clips, and condiment packets. Additionally, a container of cereal had a broken lid, leaving its contents exposed to air. Further observations revealed debris, including cups, lids, baskets, and trash, on the floor near the juice and ice machines. A roll of trash bags was improperly stored on top of a rack of clean bowls, and ear buds were found on a food preparation surface alongside cooking utensils. The molding at the base of the wall behind a food preparation surface was chipped and marred, and there was an accumulation of debris, including dirt and a metal nail, on the floor by a clean pot shelf.
Failure to Implement Physician's Orders for Medication and Care
Penalty
Summary
The facility failed to implement physician's orders for six residents, leading to deficiencies in medication administration and care. Resident 1, diagnosed with orthostatic hypotension and epilepsy, received midodrine hydrochloride nine times despite having a systolic blood pressure (SBP) above the ordered parameters. Similarly, Resident 12, with hypertension and heart failure, was administered midodrine hydrochloride and metoprolol without proper blood pressure assessment, resulting in multiple instances of medication being given outside the prescribed parameters. Resident 95, diagnosed with Alzheimer's disease and hypertension, received losartan on several occasions when their SBP was below the ordered threshold. Resident 98, with hypertension and cerebral infarction, was given carvedilol without documented heart rate assessment, contrary to physician's orders. Additionally, the facility did not adhere to physician's orders regarding the application of heel boots for Residents 7 and 17, both at risk for skin breakdown. Despite orders to apply heel boots while in bed, observations revealed that these residents were without the protective devices during multiple checks. The facility's administrator confirmed these lapses in care, acknowledging that medications were administered outside of established parameters and heel boots were not applied as ordered.
Inaccessible Call Bell for Resident
Penalty
Summary
The facility failed to ensure that a call bell was accessible for a resident, leading to a deficiency. The resident, who had diagnoses including parkinsonism, depression, and muscle weakness, was identified as being at risk for falls and having limited physical mobility. The care plan for this resident included an intervention for staff to ensure the call bell was within reach and to encourage its use for assistance. However, during an observation, the call bell was found on the floor at the head of the bed, out of the resident's reach. The resident was unaware of the call bell's location, and the situation remained unchanged during a subsequent observation.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to ensure that a baseline care plan summary was provided to the resident or their representative for two of the 33 sampled residents. According to the facility's policy, a baseline care plan should be developed within 48 hours of admission and must include instructions for person-centered care, initial goals based on admission orders, and other relevant orders. This plan should be provided in a language understandable to the resident or their representative. However, for Resident 17, admitted on an unspecified date, the baseline care plan was developed on October 8, 2024, but there was no evidence that the summary was provided to the resident or their representative. Similarly, for Resident 104, admitted on an unspecified date, the baseline care plan was developed on September 23, 2024, but again, there was no evidence that the summary was provided to the resident or their representative. The Administrator confirmed in an interview that there was no evidence of the baseline care plan summary being provided to these residents. This deficiency is a violation of the facility's policy and the regulatory requirement under 28 Pa. Code 201.18 (1) Management.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop or implement comprehensive care plans for three residents, as identified in their comprehensive assessments. Resident 11, diagnosed with muscle weakness and depression, was underweight and desired to gain weight. Despite a nutrition assessment recommending fortified foods and snacks, the resident did not receive fortified mashed potatoes as specified in the care plan on two observed occasions. The Administrator confirmed that the kitchen staff did not prepare the fortified mashed potatoes on those dates. Resident 12, with dementia and heart failure, had a Minimum Data Set Care Area Assessment indicating that psychotropic medication should be addressed in the care plan. However, there was no evidence of interventions for the psychotropic medication in the current care plan. Resident 21, diagnosed with cerebral infarction, difficulty in walking, and muscle weakness, was at risk for skin breakdown and required heel boots while in bed. Observations revealed that the heel boots were not applied on multiple occasions. The Director of Nursing confirmed the lack of documented evidence that these care areas were addressed or implemented according to the care plans.
Failure to Implement Safety Interventions and Medication Administration
Penalty
Summary
The facility failed to implement safety interventions for two residents at risk for falls and did not safely administer medications for another resident. Resident 7, who had a history of stroke, heart failure, and arthritis, was identified as being at risk for falls. The care plan specified that floor mats should be placed on both sides of the bed and the bed should be kept in the lowest position. However, multiple observations revealed that the resident's bed was elevated and lacked the required fall mats. Similarly, Resident 112, with a history of seizures and cognitive communication deficit, was also at risk for falls. Despite a previous fall from bed, observations showed that the resident's bed was not maintained in the lowest position as required by the care plan. Additionally, the facility failed to safely administer medications to Resident 53, who had diagnoses including dementia, legal blindness, and dysphagia. Physician's orders required staff to administer carvedilol and levetiracetam once daily. However, the resident was observed with a medication cup containing these medications left on the bedside table, indicating that the nurse had left them for the resident to take later. The resident had not been assessed or approved for self-administration of medications, and the Director of Nursing confirmed that the nurse should not have left the medications at the bedside.
Failure to Monitor and Assess Significant Weight Change
Penalty
Summary
The facility failed to adequately monitor and assess significant weight change for a resident at risk for weight loss. According to the facility's policy, any weight change of five percent or more should be retaken the next day for confirmation, and if verified, the dietitian should be notified in writing. The resident, who had diagnoses including dementia and adult failure to thrive, experienced a 7.1% weight loss between February and March, and continued to lose weight in April. However, there was no evidence that a second weight was obtained in March or that the dietitian was notified, as required by the policy. The resident's weight change was not assessed until April, which was confirmed by the Administrator during an interview.
Failure to Assess and Treat External Urinary Catheter
Penalty
Summary
The facility failed to properly assess and treat an external urinary catheter for a resident. The facility's policy required a physician's order for catheter use, and the nursing and interdisciplinary team were to assess and document the ongoing need for the catheter. The catheter was to be removed when no longer required. However, upon review of the clinical records, it was found that the resident, who was admitted with diagnoses including neoplasm of cranial nerves, pulmonary fibrosis, and muscle weakness, had an external urinary catheter that was not changed until September 17, 2024. There was no documentation indicating that a physician's order was obtained, the catheter was changed, or the resident's surrounding skin was assessed until that date. In an interview, the Nursing Home Administrator confirmed that staff were expected to obtain a physician's order, change the external catheter daily, and assess the resident's surrounding skin daily. However, there was no documentation to support that these actions were taken prior to September 17, 2024.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident was administered medication as prescribed by the physician. The resident, who had diagnoses of anxiety and depression, was ordered by the physician to receive an anti-anxiety medication, Lorazepam, every eight hours. However, on May 9, 2024, the resident did not receive the scheduled doses of the medication three times because it was not available. This was confirmed during an interview with the resident, who stated that staff did not always administer her medication as ordered. The Nursing Home Administrator acknowledged that the medication was not given as prescribed and that the nursing supervisor failed to obtain the medication from the emergency supply.
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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