Concordia Lutheran Health And Human Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Cabot, Pennsylvania.
- Location
- 134 Marwood Road, Cabot, Pennsylvania 16023
- CMS Provider Number
- 395684
- Inspections on file
- 29
- Latest survey
- August 8, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Concordia Lutheran Health And Human Care during CMS and state inspections, most recent first.
Kitchen equipment, specifically the walk-in cooler's cold air condenser unit, was found with a build-up of dust, grime, and debris around the fan covers and surrounding area. The Dietary Supervisor confirmed the lack of proper maintenance, resulting in unsanitary conditions and the potential for cross contamination in the kitchen.
The facility did not ensure that necessary resident information, such as care plan goals and advance directives, was communicated to receiving health care providers during transfers for several residents with complex medical needs. Additionally, written notification of the facility's bed-hold policy was not provided to residents or their representatives during multiple hospital transfers, as required by policy. These deficiencies were confirmed through record review and staff interviews.
Medications and biologicals were found left unattended and unsecured in two separate incidents: one involving a resident's medications left on a bedside dresser, and another where a pharmacy driver left bins of medications unattended in a hallway during restocking. Both a nurse and the DON confirmed the failure to follow proper medication storage procedures.
The facility did not provide residents the opportunity to vote in a recent election, as confirmed by review of policy, resident council minutes, resident interviews, and the Director of Activities.
A resident with reduced mobility and a history of falls was observed sitting in a recliner with the call bell placed out of reach on the bed. An LPN confirmed the call bell was not accessible, indicating the facility did not meet the resident's needs as required by policy.
Surveyors found that the facility did not have complete contact information for the State LTC Ombudsman program posted, as required. Posters in multiple locations were missing the name, address, and correct email for the program, and this was confirmed during staff interview.
A resident with multiple medical conditions was administered psychotropic medications, including Lorazepam and Duloxetine, without documentation of non-pharmacological interventions being attempted prior to use. The facility also failed to document required monitoring for side effects and behavioral responses to these medications, as confirmed by the DON.
A resident with a history of hip fracture, depression, migraine, and legal blindness was admitted, but the care plan did not include interventions for visual impairment despite documentation of highly impaired vision and the need for staff assistance. This omission was confirmed by staff interviews and review of records.
A resident with a long history of daily tobacco use and multiple medical conditions was not properly identified as a smoker upon admission, and the required smoking safety assessment and care plan interventions were delayed for several weeks. Facility leadership confirmed that the assessment and care planning for smoking safety were not conducted in a timely manner, resulting in noncompliance with facility policy and state regulations.
The facility did not consistently monitor and document personal refrigerator temperatures for two residents, resulting in lapses in food safety practices. Additionally, Enhanced Barrier Precautions were not implemented for two residents who required them, including one with a pressure ulcer and another with ESBL (E. Coli) in the urine, with staff observed failing to use appropriate PPE and hand hygiene.
A resident with a history of hypertension, anemia, and atrial fibrillation was not offered or administered the influenza vaccine for the current flu season, and there was no documentation of consent or education regarding the vaccine, as required by facility policy. The DON confirmed the failure to complete these steps in a timely manner.
A resident with multiple medical conditions did not receive or have documented pressure ulcer treatments as ordered by the physician on two occasions. Review of records and staff interview confirmed that required wound care was not completed or documented according to facility policy.
Surveyors found that oxygen cylinders were not properly secured in a rack in one area, and empty cylinders were stored with full ones in two storage rooms. These deficiencies were confirmed by the administrator and maintenance supervisor.
The facility did not complete one of the required semi-annual supervisory switch inspections and failed to perform the annual trip test for the dry sprinkler system, as confirmed by the maintenance director during survey review.
Kitchen staff were unable to identify or operate the manual activation for the kitchen hood fire suppression system, and this deficiency was confirmed by the administrator during interviews.
A basement laundry chute door was found to lack the required number of fusible links on its hold-open springs, preventing the door from closing as mandated. This deficiency was confirmed by both the administrator and maintenance supervisor during the survey.
A kitchen electrical receptacle near the hand sink was found without required GFCI protection during an observation, and this deficiency was confirmed by the administrator and maintenance supervisor.
The facility failed to adhere to professional standards in postmortem care for two residents. One resident with lung cancer was transferred without specifying the funeral home's name, while another with cervical cancer was incorrectly transferred to a different funeral home. The LPN on duty did not verify the correct funeral home, leading to misidentification and incorrect disposition of the bodies.
The facility failed to properly label and date food products in the kitchen, including cereal, juice, pasta, and snacks, creating potential for cross-contamination. Additionally, unsanitary conditions were observed with brown debris on fans above the dishwasher. The Dietary Supervisor confirmed these deficiencies, which increased the risk of foodborne illness.
The facility failed to assess the ability of three residents to self-administer medications safely. A resident with renal insufficiency and other conditions had medications at their bedside without orders or documentation for self-administration. Two other residents with COPD and other diagnoses were found with Trelegy inhalers at their bedsides, self-administering without proper orders or care plans. The interdisciplinary team had not evaluated the safety of self-administration for these residents, as confirmed by the DON.
The facility failed to provide appropriate catheter care for several residents, as observed by surveyors. A resident's urinary drainage bag lacked a dignity/privacy cover, while another's was placed in a wash basin on the floor. Additionally, a resident had their drainage bag in their lap, contrary to facility policy. These deficiencies were confirmed by staff interviews.
The facility failed to update care plans for two residents, resulting in care plans that did not reflect current medical needs. One resident's care plan lacked interventions for tubigrips despite physician orders, while another's omitted wanderguard interventions. The Nursing Home Administrator confirmed these omissions.
A resident with a JP drain was observed with the drain improperly managed, as it was left dangling over a chair and wheelchair, contrary to facility procedures. The resident reported discomfort, and staff acknowledged the need to secure the drain but had not done so. The DON confirmed the failure to provide appropriate care for the medical device.
A facility failed to follow standards of practice by not obtaining physician orders for the displacement of a wound vac device for a resident with a sacral pressure ulcer. The facility's policy required specific actions if the NPWT device was off for more than two hours, but the resident's physician orders lacked instructions for such an event. This deficiency was confirmed by an LPN during an interview.
The facility failed to maintain sanitary conditions of respiratory equipment for two residents and did not include the use and management of respiratory equipment in the care plans for two other residents. Observations revealed undated oxygen tubing and incorrect flow rates, while care plans lacked necessary interventions for CPAP/BIPAP and nebulizer treatments. These deficiencies were confirmed by staff interviews.
A resident with restless leg syndrome did not receive prescribed medication for two nights, and the physician was not notified of the missed doses. The facility's emergency supply contained the medication, but it was not used. The DON confirmed the failure to follow physician orders and notify the physician.
The facility failed to properly store medical supplies and biologicals in the Blankenbuehler medication room. Observations revealed a container of Micro-kill bleach wipes and a gallon of distilled water stored under the sink, and an opened bag of cheddar cheese cubes without a date/time marking in the resident pantry refrigerator. Additionally, boxes of batteries were improperly stored in the refrigerator. These findings were confirmed by an RN, indicating non-compliance with the facility's policies on medication storage and food safety.
The facility failed to follow enhanced barrier precautions for a resident with an enteral feeding tube, as staff did not wear gowns during high-contact activities, contrary to CDC guidelines. Additionally, during a dressing change for a resident with a sacral pressure ulcer, an LPN did not change gloves or perform hand hygiene, violating infection control protocols.
A resident with severe cognitive impairment and a history of wandering eloped from a facility due to inadequate supervision and a malfunctioning alarm system. The resident was found in a stairwell after falling down a flight of stairs in her wheelchair. The facility's elopement risk program was inaccurate, and staff failed to conduct head counts when alarms sounded, contributing to the incident.
The facility failed to provide necessary supervision, resulting in a resident being found at the bottom of ten stairs in a wheelchair after elopement, placing seven other residents in Immediate Jeopardy. The Nursing Home Administrator and DON did not effectively manage the facility to ensure care and supervision in accordance with professional standards and policies.
Unsanitary Walk-In Cooler Equipment in Kitchen
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary condition, specifically the walk-in cooler in the main kitchen. During an observation conducted with the Dietary Supervisor, the cold air condenser unit in the walk-in cooler was found to have a build-up of dust, grime, and dark colored debris around the fan covers and the area immediately surrounding the fans. The Dietary Supervisor confirmed the presence of this debris and acknowledged that the equipment was not properly maintained, which created the potential for cross contamination in the kitchen. The facility's policy required adherence to all local, state, and federal standards to ensure a safe and sanitary food service department, but this standard was not met in this instance.
Failure to Communicate Resident Information and Provide Bed-Hold Policy Notification During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to receiving health care providers during facility-initiated transfers for four out of six sampled residents. Specifically, the clinical records for these residents did not contain documentation that key information such as care plan goals, advance directive information, special instructions for ongoing care, resident representative contact information, and all other details necessary to meet the residents' needs were provided to the receiving providers. This lack of communication was confirmed through both clinical record review and staff interviews, including with the DON and Nursing Home Administrator. Additionally, the facility did not provide written notification of its bed-hold policy to residents or their representatives for three out of six hospital transfers. The bed-hold policy requires that residents or their representatives receive written notice within 24 hours of an emergency transfer, outlining the facility's agreement to hold a bed for an agreed-upon rate during hospitalization. Clinical record reviews for the affected residents showed no evidence that this required notification was given at the time of transfer. The residents involved had various medical conditions, including muscle wasting, anemia, dementia, reduced mobility, and dependence on supplemental oxygen. The deficiencies were identified through a combination of policy review, clinical record examination, and staff interviews, which confirmed the absence of required documentation and communication at the time of transfer and hospitalization.
Failure to Secure and Properly Store Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and secured, as required by facility policy and regulatory standards. During an observation, medications belonging to a resident with pulmonary hypertension, atrial fibrillation, and polycythemia vera were found left unattended on the resident's bedside dresser. These included a tube of Muscle Rub (Methyl salicylate/menthol), a bottle of Nystatin, and a bottle of Deep Sea Premium Saline. A registered nurse confirmed that these medications were not properly stored according to policy. Additionally, during a separate observation, three bins containing a total of 333 resident medication cards were left unsecured on a utility cart in a hallway by a pharmacy driver in the process of restocking medication carts. The pharmacy driver confirmed that the bins of medications were left unattended and unsecured. The Director of Nursing also confirmed that the facility failed to properly store medications for a resident and that the pharmacy driver left medications unattended and unsecured during a delivery.
Failure to Offer Residents Opportunity to Vote
Penalty
Summary
The facility failed to offer residents the opportunity to vote in the May 2025 election, as required by their own Resident Rights policy dated 1/7/25, which states that residents have the right to exercise their rights as citizens of the United States. Review of resident council minutes over a three-month period did not show any evidence that the facility asked residents about voting. During a resident group meeting, residents reported they were not given the opportunity to vote in the May 2025 election. The Director of Activities confirmed that the facility did not offer residents the opportunity to vote for this election.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the call bell needs of one resident, as required by its own policy. The policy stated that staff must ensure the call light is within reach of the resident and secured as needed. Resident R80, who had diagnoses including high blood pressure, reduced mobility, and repeated falls, was observed sitting in a recliner with the call bell placed on the bed, out of reach. During an interview, an LPN confirmed that the call bell was not accessible or available for the resident's use, indicating noncompliance with the facility's policy and failure to meet the resident's needs.
Incomplete Ombudsman Contact Information Posted
Penalty
Summary
The facility failed to post complete contact information for the State Long Term Care Ombudsman program as required. During an observation, posters related to the ombudsman were found on bulletin boards in three locations, but these did not include the name, address, or correct email for the program. This deficiency was confirmed during an interview with the Nursing Home Administrator, who was informed that the postings lacked the required details. The deficiency was cited under 28 Pa. Code 201.14(a) and 201.18(b)(3).
Failure to Document Non-Pharmacological Interventions and Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. According to facility policy, psychotropic medications should only be administered when non-pharmacological interventions are clinically ineffective, and their use must be supported by a specific, diagnosed, and documented condition. For one resident with diagnoses including a humerus fracture, protein-calorie malnutrition, and diabetes mellitus, the clinical record showed the use of Lorazepam and Duloxetine, both psychotropic medications. The resident received Lorazepam as needed for anxiety multiple times, but there was no documentation of non-pharmacological interventions attempted prior to administration. Additionally, the clinical record lacked evidence of side effect or behavior monitoring related to the use of psychotropic medications, as required by facility policy. The care plan indicated the need to monitor for side effects and effectiveness every shift, but this was not documented. The DON confirmed during an interview that there was no documentation of non-pharmacological interventions prior to administering as-needed psychotropic medication, nor was there monitoring in place for side effects or behaviors associated with the medication use.
Failure to Develop Care Plan for Visual Impairment
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan that included specific and individualized interventions to address the visual impairment needs of a resident. Review of the facility's policy indicated that care plans should include measurable objectives and time frames to meet all identified needs. However, for a resident admitted with diagnoses including hip fracture, depression, migraine, and documented as legally blind, the care plan did not address the resident's visual impairment. The resident's MDS assessment showed highly impaired vision, and a progress note confirmed legal blindness with a need for staff assistance in keeping belongings within reach. Despite these documented needs, the resident's care plan lacked any interventions or objectives related to visual impairment. This omission was confirmed during interviews with an LPN, the DON, and the Nursing Home Administrator, all of whom acknowledged the absence of a care plan addressing the resident's visual impairment. The deficiency was identified through review of policies, clinical records, observations, and staff interviews.
Failure to Timely Assess and Care Plan for Resident Smoking Safety
Penalty
Summary
The facility failed to timely identify and assess a resident for smoking safety upon admission, despite clear documentation from the hospital and physician that the resident was a daily smoker with a long history of tobacco use. The facility's policy required that all residents be asked about tobacco use during the admission process and at each MDS assessment, with further assessment for those who smoke to determine supervision needs. However, the resident's smoking status was not properly identified at admission, and the required smoking safety assessment was not completed until five weeks later. Additionally, interventions related to smoking were not implemented in the resident's care plan until several days after the assessment was finally completed. The resident had significant medical diagnoses, including high blood pressure, peripheral vascular disease, and chronic obstructive pulmonary disease, and required supervision to smoke. Facility leadership confirmed that the assessment and care planning for smoking safety were not conducted in a timely manner, resulting in a failure to provide adequate supervision and accident hazard prevention as required by facility policy and state regulations.
Failure to Monitor Refrigerator Temperatures and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to properly monitor and document the temperatures of personal refrigerators for two residents, as evidenced by missing temperature log entries for two consecutive days for each resident. Observations confirmed that the required daily temperature checks were not consistently performed, and staff interviews verified that the monitoring process was not followed as per facility policy, resulting in a lack of assurance that food was being stored safely for these residents. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for two residents who met the criteria for such precautions. One resident with an unhealed Stage III pressure ulcer did not have EBP in place, despite clinical documentation and physician orders indicating the need. Another resident with a physician order for contact isolation due to ESBL (E. Coli) of the urine was not provided with the correct isolation precautions, and staff were observed entering the room and administering medication without appropriate personal protective equipment or hand hygiene. These failures were confirmed by the facility's Infection Preventionist.
Failure to Obtain Consent and Administer Influenza Vaccine
Penalty
Summary
The facility failed to complete the required consent process and timely administration of the influenza vaccination for one resident. According to the facility's Infection Prevention and Control Program policy, all residents are to be offered the influenza vaccine between October 1st and March 31st each year, with documentation of education and consent in the medical record. Review of the clinical record for a resident admitted during the relevant period showed no evidence that the influenza vaccine was offered or administered for the 2024-2025 flu season, nor was there documentation of consent or education regarding the vaccine. The Director of Nursing confirmed this lapse during an interview. The resident in question had diagnoses including high blood pressure, anemia, and atrial fibrillation.
Failure to Provide and Document Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that a resident received proper treatment for a pressure ulcer as required by facility policy and physician orders. The resident, who had diagnoses including high blood pressure, hemiplegia, and hyperlipidemia, was admitted with a coccyx wound that required specific wound care interventions. Physician orders directed that the wound be cleansed with normal sterile saline, followed by the application of collagen particles, medical grade honey, calcium alginate, and a bordered gauze dressing on a daily basis. These treatments were to be documented on the Treatment Administration Record (TAR). Review of the clinical records and TAR revealed that the prescribed wound care was not documented as completed on two separate occasions during the month. Specifically, there was no documentation of the treatment being performed during the day shift on two different dates, despite active physician orders. During an interview, the LPN Wound Nurse confirmed that the facility did not ensure the resident received the required pressure ulcer treatment as outlined in the orders and facility policy.
Improper Oxygen Cylinder Storage in Multiple Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain proper storage of oxygen cylinders in three separate storage areas. On the second floor, four oxygen cylinders were found in the RNAC office without being secured in a rack or similar device to prevent them from tipping over. Additionally, in the Siegert Hall O2 storage room on the second floor and the Buchman Hall O2 storage room on the first floor, empty or used oxygen bottles were stored in racks designated for full bottles. These deficiencies were confirmed during interviews with the administrator and maintenance supervisor. The observations indicated that the facility did not follow required protocols for segregating empty and full cylinders, nor did it ensure that cylinders were properly secured to prevent accidents. No information about specific residents or their medical conditions was provided in the report.
Plan Of Correction
Oxygen cylinders immediately placed into oxygen holders. Empty/used bottles moved to storage in used oxygen cylinder rack. Education will be provided to staff to not place used oxygen cylinders in full oxygen cylinder rack. NHA or designee will audit oxygen cylinders for appropriately placed into oxygen holders and only full oxygen cylinders placed into full oxygen cylinder rack weekly x 4 then monthly until substantial compliance achieved. The results of these audits will be reviewed quarterly by the Quality Assurance and Quality Improvement committee for further analysis and recommendation.
Failure to Complete Required Sprinkler System Inspections
Penalty
Summary
The facility failed to comply with sprinkler system maintenance regulations for two out of four systems, as identified during a document review and interview. Specifically, one of two required semi-annual supervisory switch inspections was not completed, and the annual trip test for the dry system was also not performed. These deficiencies were confirmed by the maintenance director during the survey, indicating that the necessary inspections had not been conducted at the time of review.
Plan Of Correction
Education will be provided to maintenance staff for schedule of annual trip test and semi-annual supervisory switch inspection. Annual inspection will be completed 8/14/25 and full flow trip dry system will be completed 8/15/25. Maintenance director or designee will audit compliance with dry system annual trip test and semi-annual supervisory switch inspection quarterly until substantial compliance is achieved. The results of these audits will be reviewed quarterly by the Quality Assurance and Quality Improvement committee for further analysis and recommendation.
Kitchen Staff Unaware of Hood Fire Suppression System Operation
Penalty
Summary
The facility failed to maintain proper knowledge and operation of the kitchen hood fire suppression system, as evidenced by document review and staff interviews. During the review, kitchen staff members were unable to identify the location or explain the operation of the manual activation for the hood fire suppression system. This deficiency was confirmed by the administrator during the interview process. No information was provided regarding any residents' medical history or condition at the time of the deficiency.
Plan Of Correction
Education will be provided to dietary employees for ansul system. Dietary manager or designee will audit knowledge of location and operation of ansul system weekly x 3 weeks then monthly until substantial compliance achieved. The results of these audits will be reviewed quarterly by the Quality Assurance and Quality Improvement committee for further analysis and recommendation.
Failure to Maintain Self-Closing Mechanism on Laundry Chute Door
Penalty
Summary
The facility failed to maintain proper self-closing mechanisms on a vertical opening door, specifically the basement laundry chute door. During an observation, it was found that the chute door did not have the required number of fusible links on its hold-open springs, with only one of the two necessary fusible links installed. This deficiency prevented the chute door from closing as required. The issue was confirmed in an interview with the administrator and maintenance supervisor.
Plan Of Correction
Fusible link replaced immediately at time of survey. Weekly audits to ensure fusible link is installed will be completed by Maintenance or designee weekly for four weeks. After four weeks, audits will continue monthly. The results of these audits will be reviewed quarterly by the Quality Assurance and Quality Improvement committee for further analysis and recommendation.
Lack of GFCI Protection on Kitchen Electrical Receptacle
Penalty
Summary
During an observation conducted on July 30, 2025, at 11:36 a.m., it was found that an electrical receptacle located in the kitchen near the hand sink did not have ground fault circuit interrupter (GFCI) protection as required. This deficiency was confirmed through interviews with both the administrator and the maintenance supervisor at the same time. The report specifically notes that this issue was present in one of over twenty rooms observed. No additional details regarding patient involvement, medical history, or the condition of any residents at the time of the deficiency are provided in the report.
Plan Of Correction
Education will be provided to maintenance. All outlets within 6 feet of a water source are GFCI. The outlet by the hand sink was replaced to be GFCI on 7/30/25. The dietary manager or designee will audit the outlet by the hand sink to ensure it is GFCI weekly for 4 weeks. The results of these audits will be reviewed quarterly by the Quality Assurance and Quality Improvement committee for further analysis and recommendation.
Misidentification of Residents' Transfer Destinations Postmortem
Penalty
Summary
The facility failed to adhere to professional standards of quality care in the postmortem handling of two residents, identified as CRR1 and CRR2. Resident CRR1, who had been diagnosed with lung cancer, hypertension, and chronic obstructive pulmonary disease, ceased to breathe at 2:32 a.m. The family and the chosen funeral home, Trenz Funeral Home, were contacted, and the body was picked up at 4:52 a.m. However, the transfer/discharge report did not specify the funeral home's name. Similarly, Resident CRR2, diagnosed with cervical cancer, anxiety, and hypertension, ceased to breathe at 1:55 a.m. The son was present, and Skirpan Funeral Home was notified, but the transfer/discharge report incorrectly indicated that Trenz Funeral Home took possession of the body. The facility's investigation revealed that the funeral home that took possession of Resident CRR2 realized the face sheet did not match the expected individual. Upon confirmation with the family, it was determined that the body was not their family member. The facility was notified, and Skirpan Funeral Home confirmed that the body in their possession was Resident CRR1, not CRR2. The Nursing Home Administrator confirmed that the LPN on duty failed to verify the correct funeral home, leading to the misidentification of the residents' transfer destinations. This failure to provide care and services according to accepted clinical practice standards resulted in the incorrect disposition of the bodies for both residents.
Improper Food Labeling and Unsanitary Conditions
Penalty
Summary
The facility failed to adhere to its policy on date marking for food safety, as observed during a survey of the main designated kitchen. Several food items in the dry storage area, including a bag of cereal, boxes of pineapple juice, a bag of elbow pasta, and various snack boxes, were found without labels or dates. Additionally, a bag of meat in the walk-in freezer and crates of drinks stored on the floor in the walk-in cooler were also not properly labeled or dated. This lack of proper labeling and dating of food products created the potential for cross-contamination and foodborne illness. Furthermore, the facility did not maintain sanitary conditions in the dish room and kitchen. Observations revealed brown debris on wall and floor fans located above the clean side of the dishwasher. These unsanitary conditions were confirmed by the Dietary Supervisor, who acknowledged the facility's failure to maintain proper food labeling and sanitary conditions, thereby increasing the risk of foodborne illness.
Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine the ability of three residents to self-administer medications, as required by their policy. Resident R77, who has renal insufficiency, atrial fibrillation, and high blood pressure, was found with Preparation H and a roll-on muscle relaxant at their bedside without any physician orders or documentation for self-administration. The care plan for Resident R77 did not include these medications or a plan for self-administration, and the interdisciplinary team had not assessed the safety of self-administration for these medications. Similarly, Resident R281, diagnosed with COPD, asthma, and bronchitis, was observed with a Trelegy inhaler at their bedside, which they self-administered without an order indicating self-administration. Resident R24, with COPD, anemia, and dysphagia, also had a Trelegy inhaler at their bedside without a self-administration order. Both residents' care plans lacked a plan to manage or determine self-administration practices, and there was no documentation of the interdisciplinary team's assessment for safe self-administration. The Director of Nursing confirmed these deficiencies.
Deficiencies in Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for residents with urinary catheters, as evidenced by observations and staff interviews. The facility's policy on indwelling catheter use and removal requires that catheters be anchored to prevent tension, secured to facilitate urine flow, and positioned below the bladder level. However, several deficiencies were noted during observations. Resident R38's urinary drainage bag lacked a dignity/privacy cover, which was confirmed by an LPN. Similarly, Resident R93 and Resident R99 also had urinary drainage bags without dignity/privacy covers, as confirmed by staff. Additionally, Resident R63 was observed with a urinary drainage bag placed in a wash basin on the floor, which was confirmed by an LPN. Resident R78 was seen with a urinary drainage bag in his lap while sitting in a common area, which was later moved below the bladder by an RN. These observations indicate a failure to adhere to the facility's catheter care policy, potentially compromising the residents' dignity and increasing the risk of urinary tract infections.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise and update care plans for two residents, which did not accurately reflect their current medical needs. Resident R54, who was diagnosed with hypertension, coronary artery disease, and diabetes, had physician orders for the application of tubigrips on the bilateral lower extremities. However, the care plan for Resident R54 did not include any interventions related to the use of tubigrips, despite the treatment being administered as ordered. Similarly, Resident R86, who had diagnoses of congestive heart failure, a left artificial hip joint, and chronic kidney disease, had physician orders for the use of a wanderguard every shift. The care plan for Resident R86 also failed to include interventions for the wanderguard. The Nursing Home Administrator confirmed that the facility did not update the care plans for these residents to include the necessary interventions, as required by the facility's policy and regulatory standards.
Improper Management of JP Drain for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care for a medical device for Resident R283, as observed and documented by surveyors. The resident, who was admitted with multiple diagnoses including rib fractures, atrial fibrillation, heart failure, and a percutaneous drain placement, had a physician's order to have the JP drain emptied every shift and the drainage documented. However, observations on two separate occasions revealed that the JP drain was improperly managed, as it was seen dangling over the side of a chair and a wheelchair, respectively. This improper handling of the drain was contrary to the facility's procedure, which required the drain to be secured to the resident's clothing to prevent pulling at the insertion site. Interviews conducted with the resident and staff further highlighted the deficiency. The resident reported discomfort and soreness due to the pulling of the drain on her skin. A registered nurse acknowledged the need to secure the drain but had not done so at the time of observation. The Director of Nursing confirmed the facility's failure to ensure proper care and management of the medical device for the resident, which was a violation of the facility's resident care policies and nursing services regulations.
Failure to Obtain Physician Orders for Wound Vac Displacement
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with standards of practice, specifically regarding the management of a wound vac device. The facility's policy on Negative Pressure Wound Therapy (NPWT) indicated that the device should not be left off for more than two hours, and if it is, the old dressing should be removed and a new NPWT dressing or an alternative absorptive dressing should be applied as prescribed. However, the clinical records for a resident admitted with a diagnosis of sepsis, depression, and a pressure ulcer of the sacral region showed that the physician orders did not include instructions for the displacement of the wound vac device. This deficiency was confirmed during an interview with an LPN, who acknowledged the failure to follow standards of practice and obtain necessary physician treatment orders for the resident's dressing displacement.
Deficiencies in Respiratory Equipment Management and Care Planning
Penalty
Summary
The facility failed to maintain sanitary conditions of respiratory equipment for two residents and did not include the use and management of respiratory equipment in the care plans for two other residents. Specifically, the facility did not ensure that the CPAP/BIPAP machine for one resident was included in their care plan, despite physician orders requiring regular cleaning and maintenance of the equipment. The Director of Nursing confirmed this omission during an interview. Another resident's care plan also lacked interventions and goals for the use and management of nebulization breathing treatments, even though the resident had physician orders for regular and as-needed nebulizer treatments. The Resident Nurse Assessment Coordinator confirmed the absence of these details in the care plan. Additionally, the facility did not maintain sanitary conditions for respiratory equipment for two residents. Observations revealed that oxygen tubing and humidification were not dated as required, and the oxygen concentrator was set at an incorrect flow rate for one resident. These issues were confirmed by LPNs during interviews, and the Nursing Home Administrator and Director of Nursing acknowledged the facility's failure to maintain sanitary conditions and proper care planning.
Failure to Administer Medication and Notify Physician
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician and did not notify the physician of missed medications for a resident. The resident, who was a new admission, had a diagnosis of restless leg syndrome, cellulitis, and lymphedema. The resident reported not receiving his medication for restless leg syndrome for two consecutive nights. The physician's orders indicated that the resident was to receive ropinirole, an extended-release oral tablet, at bedtime. The medication administration record for the resident showed that the medication was marked as unavailable on two consecutive nights. Nursing notes confirmed that the medication was not available, and there was no documentation indicating that the physician was notified of the missed doses. The facility's emergency medication supply did contain doses of ropinirole, but these were not utilized. The Director of Nursing confirmed the failure to follow physician orders and notify the physician of the missed medication.
Improper Storage of Medical Supplies and Biologicals
Penalty
Summary
The facility failed to properly store medical supplies and biologicals in the Blankenbuehler medication room, as observed during a survey. Specifically, a container of Micro-kill bleach wipes and a gallon of distilled water were found stored under the sink, which is not in accordance with the facility's policy on medication storage. Additionally, in the resident pantry refrigerator, an opened bag of cheddar cheese cubes was found without a date/time marking, and boxes of AA, 9 Volt, and AAA batteries were stored there, which is inconsistent with proper storage practices for medications and biologicals. These observations were confirmed by a Registered Nurse (RN) during an interview, indicating a lapse in adherence to the facility's policies on medication storage and food safety. The facility's policies, last reviewed on 1/16/24, require medications to be stored safely, securely, and properly, and food items to be date-marked when opened or prepared. The failure to comply with these policies resulted in the cited deficiencies.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions for a resident with an enteral feeding tube. Despite the presence of a sign indicating the need for gloves and a gown during high-contact activities, a Licensed Practical Nurse (LPN) administered medication via the feeding tube without donning a gown. This action was contrary to the safest standards outlined by the CDC. The LPN acknowledged the oversight during an interview. Additionally, a Registered Nurse (RN) was observed administering a feeding bolus without wearing a gown, mistakenly believing that gowns were only necessary for changing or bathing residents. The RN Infection Preventionist did not confirm the need for a gown, despite CDC guidelines. Another deficiency was observed during a dressing change for a resident with a sacral pressure ulcer. The Licensed Practical Nurse (LPN) removed the soiled dressing, cleansed the wound, and packed it without changing gloves or performing hand hygiene. This action was confirmed by the LPN during an interview, indicating a failure to follow proper infection control procedures. The report highlights the facility's failure to implement and adhere to infection prevention and control protocols, specifically regarding enhanced barrier precautions and hand hygiene during wound care. These deficiencies were identified through observations and staff interviews, revealing a lack of compliance with established guidelines and standards of practice.
Inadequate Supervision Leads to Resident Elopement and Fall
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as at risk for elopement, resulting in the resident exiting to an unsupervised area without the facility's knowledge. The resident, who had a history of dementia with severe cognitive impairment, was found in a stairwell after reportedly falling down a flight of stairs in her wheelchair. The alarm system, which was supposed to alert staff to such incidents, did not sound, and the resident was last seen 45 minutes prior to the incident. The resident's care plan identified her as at risk for wandering and elopement, and interventions included the use of a wander alert bracelet. However, observations revealed that the resident did not have the wander guard on her person or wheelchair as ordered. Staff interviews indicated a lack of consistent response to alarms and inadequate monitoring of residents with wandering behaviors. Additionally, the facility's elopement risk program was found to be inaccurate, with incorrect room listings for residents at risk. The incident highlighted several lapses in the facility's procedures, including the failure to conduct head counts when alarms sounded and the improper posting of access codes at stairwell doorways. Staff interviews revealed confusion and inconsistency in the implementation of elopement prevention measures, contributing to the resident's unsupervised exit and subsequent fall.
Removal Plan
- Resident R1's care plan was updated to reflect wandering behaviors and ensure supervision and monitoring are in place.
- All residents will be evaluated with the elopement risk assessment to ensure wandering/elopement behaviors were identified and care planned as needed and reflect adequate supervision and monitoring.
- New steps implemented were verified of codes to doors removed and door alarm audits initiated. Facility obtained quotes to install wander guard system to all second-floor exit doors.
- Ad Hoc QAPI (Safety Meeting) including the DON, Medical Director, Administrator, Therapy, Social Services, and Human Resources was conducted.
- Education on the elopement policy and procedure, wander guard system was initiated by DON/designee.
- A new education will be initiated to educate on elopement policy, wandering identification and steps to take once risk is identified, education includes process once risk is identified, if resident is actively exit seeking or have any of the signs of elopement risk, staff will initiate every 15 minutes checks and ensure wander guard is in place until the interdisciplinary team meet. An Email to the Activities Department to update the elopement risk program posting, then activities will distribute to all units and departments.
- All staff were previously educated annually, and upon hire on the facility elopement policy.
- All staff will be educated on recognizing signs and symptoms of resident elopement before the start of their next shift with follow-up to ensure understanding and compliance.
- Monitoring - all residents identified as exit seeking/wandering will be audited by the DON/Designee for elopement monitoring, supervision, and interventions daily by five days, twice a week by four weeks, and then weekly by one month. Results of the reviews will be submitted to the facility Quality Assurance and Process Improvement Committee for review and development of an action plan as needed.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide necessary supervision to prevent elopement, resulting in a significant incident where a resident was found at the bottom of ten stairs in a wheelchair after eloping. This incident placed seven other residents in Immediate Jeopardy. The Nursing Home Administrator and Director of Nursing did not effectively manage the facility to ensure that residents received care and supervision in accordance with professional standards, facility policies, and physician orders. This lack of supervision and management oversight led to a breach in the fundamental principles of treatment and care for the residents.
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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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