Complete Care At Lehigh Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Macungie, Pennsylvania.
- Location
- 1718 Spring Creek Road, Macungie, Pennsylvania 18062
- CMS Provider Number
- 395939
- Inspections on file
- 18
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Complete Care At Lehigh Llc during CMS and state inspections, most recent first.
A resident with a history of fractured femur, CVA, and osteoarthritis had a physician order for diclofenac sodium gel to be applied to the lower extremities four times daily for pain, but multiple scheduled doses were not given because the medication was not available from the pharmacy. Documentation on the TAR indicated missed applications with references to nursing notes, which stated the gel was unavailable, and the DON confirmed that the ordered medication was not applied as prescribed due to pharmacy non-availability.
Two residents with intact cognitive abilities were found self-administering medications, including Fluticasone nasal spray, multivitamin gummies, Tylenol, and CBD gummies, without documented interdisciplinary assessment or secured storage, contrary to facility policy.
A resident with multiple sclerosis and diabetes was inaccurately coded as being on dialysis in the MDS assessment, despite no supporting documentation in the clinical record. The DON confirmed the error during staff interview.
A resident who was dependent on staff for all ADLs, including grooming and personal hygiene, was repeatedly observed lying in bed with dirty fingernails and not dressed, indicating that staff did not provide the necessary assistance as required by the care plan and clinical assessment.
A resident with hypertension and heart failure received Propranolol HCI on multiple occasions when their systolic blood pressure was below the physician-ordered threshold. The DON confirmed that staff administered the medication outside of the prescribed parameters.
A resident at risk for pressure ulcers and with a current heel wound was observed multiple times without prescribed Medix boots in place, despite physician orders and care plan interventions requiring their use at all times. The boots were found on the floor, and the resident's heels were directly on the bed, indicating staff did not follow necessary pressure ulcer prevention measures.
A resident with cognitive impairment and multiple diagnoses fell while returning to bed. Although x-rays were ordered following the incident, the responsible party was not informed until the next day, contrary to the facility's protocol requiring immediate notification.
The facility failed to maintain sanitary conditions in the kitchen, with the dish machine not achieving the correct sanitizer concentration and black substance on surrounding walls. A dietary employee did not check the sanitizer concentration, and the Director of Dietary confirmed this was against protocol.
The facility failed to maintain a clean and safe environment in two shower rooms. Observations revealed dirty and damaged shower chairs, a leaking shower head, and dirty lift wheels in both the first-floor and second-floor central baths.
A facility failed to accurately complete the MDS assessment for a resident receiving hospice services. Despite a physician's order for hospice care, the MDS did not reflect this status. The DON confirmed the oversight during an interview.
A resident with congestive heart failure had a physician's order for daily weight monitoring and provider notification for significant weight gain. The facility failed to obtain the resident's weight on multiple occasions and did not notify the physician of a 3.7-pound weight gain in 24 hours. The DON confirmed these deficiencies.
The facility failed to implement interventions for two residents to prevent decline in range of motion. A resident with muscle weakness did not receive a recommended daily restorative nursing program for arm movement. Another resident with dementia and hemiplegia was observed without a required carrot splint on her right hand, despite physician orders and care plan instructions.
Failure to Obtain and Administer Ordered Pain Medication
Penalty
Summary
The facility failed to ensure that a physician-ordered medication was available and administered as prescribed for one resident. The resident had diagnoses including a fractured femur, a stroke, and osteoarthritis, and on February 7, 2026, a physician ordered diclofenac sodium external gel to be applied to the resident’s lower extremities four times daily for pain related to osteoarthritis. Review of the February 2026 Treatment Administration Record showed that on February 8, 2026, all four scheduled applications, and on the morning of February 9, 2026, were marked as “other see notes.” Nursing notes for those dates documented that the diclofenac sodium gel was not applied because it was not available from the pharmacy. In an interview on February 11, 2026, the Director of Nursing confirmed that the medication had not been applied as ordered due to its unavailability from the pharmacy on the identified dates. This deficiency reflects a failure to provide pharmaceutical services to meet the resident’s needs and to ensure that ordered medications were obtained and available for use as prescribed.
Failure to Assess and Document Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess two residents for their ability to self-administer medications, as required by facility policy. For one resident with diagnoses including heart failure, diabetes, depression, and mild cognitive impairment, observations revealed multiple medications, including a bottle of Fluticasone nasal spray and multivitamin gummies, left unsecured on the bedside table. The resident reported self-administering these medications, but there was no documentation of an interdisciplinary team assessment or approval for self-administration, nor was there evidence of secured storage to prevent access by others. Another resident, diagnosed with high blood pressure and high cholesterol, was found to have a bottle of Tylenol and CBD gummies unsecured in a dresser drawer. This resident also reported self-administering Tylenol daily, with no documentation of an assessment for self-administration or secured storage of the medications. Interviews with staff and the administrator confirmed that neither resident had been assessed for self-administration of medications as required by facility policy.
Inaccurate MDS Assessment Coding for Resident
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident. Clinical record review showed that the resident had diagnoses of multiple sclerosis and diabetes. However, the MDS assessment incorrectly indicated that the resident was on dialysis, despite there being no documentation in the clinical record to support this. During an interview, the Director of Nursing confirmed that the MDS assessment was inaccurately coded and that the resident was not on dialysis at the time.
Failure to Provide Required ADL Assistance for Dependent Resident
Penalty
Summary
A resident with diagnoses including acute respiratory failure, chronic obstructive pulmonary disease, and a disorder of the brain was found to be dependent on staff for activities of daily living (ADLs) and had an ADL self-care deficit as documented in the clinical record and care plan. Observations conducted over two consecutive days revealed that the resident remained in bed with dirty fingernails, was not dressed, and had not received necessary assistance with grooming and personal hygiene from staff. Staff interviews confirmed that the resident was dependent on staff for all ADL care, yet appropriate assistance was not provided during the observed periods. These findings were based on clinical record review, direct observation, and staff interview, demonstrating a failure by the facility to ensure that required assistance with grooming and personal hygiene was provided to a resident who was unable to perform these tasks independently.
Failure to Follow Medication Administration Parameters
Penalty
Summary
Staff failed to follow physician's orders for a resident diagnosed with hypertension and heart failure. The physician had ordered Propranolol HCI to be administered twice daily, with specific parameters not to give the medication if the resident's systolic blood pressure was below 110 mm/Hg or if the heart rate was less than 55. Clinical record review showed that the medication was administered on three occasions in July and three occasions in August when the resident's systolic blood pressure was under 110 mm/Hg. The Director of Nursing confirmed that the medication was given outside of the established parameters.
Failure to Apply Pressure-Relieving Devices as Ordered
Penalty
Summary
A resident with diagnoses including acute respiratory failure, COPD, and a brain disorder was identified as being at risk for pressure sores and was dependent on staff for activities of daily living. The care plan included interventions to prevent skin impairment due to incontinence, such as elevating both heels off the bed with pillows and the application of Medix boots (pressure-relieving boots) at all times, as ordered by the physician. Clinical documentation indicated the presence of a pressure sore on the resident's right heel, with recommendations to float the heels using the prescribed boots. Despite these interventions and orders, multiple observations over two consecutive days revealed that the resident was lying in bed without the Medix boots in place, with both heels resting directly on the bed. The boots were seen on the floor in the resident's room during all observed periods. The DON confirmed that the boots were to be applied at all times as a pressure-relieving device. This failure to implement prescribed interventions resulted in the facility not providing necessary treatment and services to promote healing and prevent new pressure sores for the resident.
Failure to Notify Responsible Party of Resident's Fall
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for one of the residents. The resident, who had diagnoses including diabetes, polyneuropathy, and muscle weakness, experienced a fall on October 10, 2024, at 7:25 a.m. while returning to bed after using the toilet. Following the fall, a nurse's note at 11:05 a.m. indicated new physician orders for x-rays of the right hip, pelvis, and thoracic and lumbar spine. However, the responsible party was not informed of the fall and the subsequent x-rays until the next day at 3:15 p.m. The Director of Nursing confirmed that staff are required to notify the responsible party immediately after such incidents.
Sanitation Deficiency in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. The dish machine did not achieve the appropriate concentration of sanitizer solution, which should be between 50-100 parts per million, for three full cycles. Additionally, there was a black substance on the walls surrounding the dish machine, indicating a lack of cleanliness. A backflow of water was observed from a drain on the dish room floor, and debris was found on a windowsill in the food preparation area. During an interview, a dietary employee admitted to not checking the concentration of the sanitizer solution during the morning operation. The Director of Dietary confirmed that staff are required to check and accurately record the concentration of the sanitizer solution while the dish machine is operating, as per the facility's protocol.
Facility Fails to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in two shower rooms, specifically the first-floor and second-floor central baths. Observations in the first-floor central bath revealed a shower chair with a black substance at the base, another chair with brown smudges on the seat and a black substance at the base, and a bariatric shower chair with hair on the seat and base. Additionally, the wheels on two lifts were dirty. In the second-floor central bath, a shower chair had a cracked seat, a leaking shower head was observed in the left shower stall, the wheels on three lifts were dirty, and a shower chair had a black substance under the seat.
Inaccurate MDS Assessment for Hospice Services
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the current status of a resident. Specifically, for one of the 24 sampled residents, the MDS assessment did not indicate that the resident was receiving hospice services, despite a physician's order for hospice care being in place since March 11, 2024. This discrepancy was confirmed during an interview with the Director of Nursing on July 12, 2024, who acknowledged that the MDS assessment did not accurately identify the resident's hospice status.
Failure to Implement Physician's Orders for Resident with CHF
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with congestive heart failure. The physician's order required staff to obtain a daily weight for the resident and notify the provider if there was a weight gain of two pounds or more in one day. However, there was no evidence that the resident's weight was obtained or that the resident refused to be weighed on several specified dates. Additionally, on one occasion, the resident experienced a 3.7-pound weight gain in 24 hours, but the staff did not notify the physician of this significant change. The Director of Nursing confirmed the lack of evidence regarding the weighing of the resident and the notification of the physician about the weight change.
Failure to Implement Range of Motion Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent further decline and improve range of motion for two residents. Resident 35, diagnosed with muscle weakness, was recommended a daily restorative nursing program (RNP) for active range of motion to both arms following an occupational therapy discharge assessment. However, there was no evidence that this program was implemented, as confirmed by the Director of Rehabilitation Services. Resident 54, who had diagnoses including dementia, hemiplegia, and a right hand contracture, was ordered by a physician to have a carrot splint applied to her right hand at all times. Despite this, multiple observations revealed that the splint was not in place while the resident was in her chair, indicating a failure to follow the care plan designed to prevent limitation in movement.
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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