Crosslands
Inspection history, citations, penalties and survey trends for this long-term care facility in Kennett Square, Pennsylvania.
- Location
- 1660 East Street Road, Kennett Square, Pennsylvania 19348
- CMS Provider Number
- 395388
- Inspections on file
- 18
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Crosslands during CMS and state inspections, most recent first.
The facility did not follow its own Criminal Record/FBI Check Policy when hiring a staff member who had not been a state resident for the required two-year period. Policy required an FBI national criminal background check for such individuals upon hire, but review of the employee’s personnel file showed no evidence that an FBI check was initiated or completed. The NHA confirmed that the employee did not meet the two-year residency requirement and that the FBI check had not been done, resulting in a failure to properly screen the individual for findings of abuse, neglect, exploitation, or theft before employment.
A resident discharged to independent living did not have proper documentation of medication disposition completed at discharge. Facility policy required the licensed nurse to remove all medications from the med cart, count remaining quantities, and document the amounts and disposition on a printed eMAR or in an ID note, then ensure it was entered into the EHR. For this resident, the nurse discharge summary only stated that all medications were given to the resident, without recording the quantities of medications. The DON later confirmed that the required documentation of medication disposition was not completed, resulting in a failure to follow the facility’s clinical records policy.
A resident's care plan for continence was not followed, leading to a fall and injury. The resident, who was supposed to be toileted at specific intervals, was last toileted at 9:00 a.m. and later found on the floor with a hematoma. The facility's documentation and staff interviews confirmed the care plan was not adhered to, resulting in the fall.
A resident fell from a Broda chair, sustaining a hematoma and other symptoms, due to the facility's failure to follow the resident's toileting care plan. Despite the incident and the facility's policy requiring investigation of suspected abuse or neglect, no investigation was conducted.
A facility failed to ensure accurate assessments for a resident, as the discharge MDS indicated an incorrect discharge location. The resident was marked as discharged to an acute hospital, but records showed they were discharged home. This error was confirmed by the RNAC during an interview.
The facility failed to notify physicians in a timely manner of multiple medication errors experienced by 15 residents. The errors, originating from the contracted pharmacy, were identified through internal audits. Despite the findings, attending physicians were not informed until much later, as confirmed by the DON and NHA.
The facility failed to address pharmacy delivery errors, resulting in 70 medication errors for 15 residents. These errors were due to late deliveries from the contracted pharmacy, leading to missed doses of critical medications for conditions such as pain, glaucoma, calcium deficiency, insomnia, and more. The facility is now seeking a new pharmacy to meet residents' needs.
Failure to Obtain Required FBI Background Check Prior to Hiring Staff
Penalty
Summary
The facility failed to thoroughly screen an individual prior to hire by not obtaining a required FBI criminal background check for one of five employee records reviewed (Employee E3). The facility’s Criminal Record/FBI Check Policy, revised March 14, 2022, required that a criminal record check and, when applicable, an FBI national check be processed for all staff members upon hire, specifying that an FBI check is required if the staff member is not a current Pennsylvania resident or has not been a state resident for the two years preceding the application. Review of Employee E3’s personnel record showed that this employee was hired on December 18, 2025, with no evidence that an FBI check had been initiated or completed. In an interview on February 20, 2026, at 12:43 p.m., the Nursing Home Administrator confirmed that Employee E3 had not been a Pennsylvania resident for the required two-year period and that the FBI check had not been completed, resulting in noncompliance with the facility’s policy and regulatory requirements related to screening for abuse, neglect, exploitation, or theft findings.
Failure to Document Medication Disposition at Discharge
Penalty
Summary
The facility failed to ensure accurate documentation of the disposition of medications upon discharge for one discharged resident. Facility policy on disposition of noncontrolled medications, revised in December 2025, required the licensed nurse to remove all of a discharged resident’s medications from the medication cart, count the remaining quantities, and document the disposition by printing the resident’s eMAR, recording the amounts of medications returned to the pharmacy on the printout, dating and initialing it, and scanning it into the EHR; alternatively, the nurse could document in an ID note the medication names, dosages, amounts remaining, and disposition. Clinical record review for Resident 51, who was discharged to independent living on December 19, 2025, showed that the nurse discharge summary stated all medications were given to the resident, but did not record or document the quantity of medications. In an interview on February 20, 2026 at 1300, the Director of Nursing confirmed that the required documentation of medication disposition was not completed for this resident, constituting noncompliance with 28 Pa. Code 211.5(d)(f) regarding clinical records.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to adhere to a resident's care plan, resulting in a fall and subsequent harm. Resident 52, who had a care plan for continence management, was not toileted according to the specified schedule. The care plan required checks and changes upon waking, before bed, before and after meals, and at specific times during the night. However, the resident was last toileted at 9:00 a.m., and the fall occurred later that morning. The resident was found on the floor with a large hematoma on the forehead, complaining of dizziness and an upset stomach, and was subsequently transported to the emergency room for evaluation. The facility's documentation and staff interviews revealed that Resident 52 had been repositioned in a Broda chair multiple times before the fall, indicating attempts to move forward in the chair. Despite these observations, the care plan was not followed, as the resident was not toileted as required. The post-fall investigation confirmed that the root cause of the fall was the failure to follow the toileting care plan, leading to the resident's fall and injury.
Plan Of Correction
In accordance with Facility Policy-Comprehensive Person-Centered Care Plan (#11.01), the Interdisciplinary Team will meet each resident's goals, based on a comprehensive assessment of the resident's physical, psychological, social and spiritual needs. In addition, in accordance with Facility Policy - Minimum Data Set (MDS) Completion (#11.02), residents residing in skilled nursing will be assessed by the Interdisciplinary Team upon admission, annually, quarterly and with significant change in condition. A review of Resident #52 indicated the facility completed assessments for reference periods 5-14-24 to 5-20-24 (Comprehensive Admission Assessment); 8-14-24 to 8-20-24 (Quarterly Assessment) and 11-13-24 to 11-29-24 (Quarterly Assessment). A comprehensive review of Resident #52 Care Plans was completed January 23, 2025 by the Interdisciplinary Team and found to be current. All resident care plans are reviewed annually, quarterly and with significant change in condition. In accordance with the Facility Policy 5.13 - Resident Info SNAP Sheet, the Facility will conduct an audit using the Care Plan Audit Form of all current resident Care Plans, covering Activities of Daily Living, Continence and Falls Prevention Care Plans to ensure Care Plans are current no later than March 7, 2025. Findings will be reported at the next quarterly Quality Assurance Committee meeting. Utilizing a Care Plan Monitoring Tool, beginning February 17th, 2025, a Facility staff member/designee shall monitor 10% of current residents weekly for the first four weeks to ensure care plans of current residents are being followed. Thereafter, monitoring of 10% of current residents will occur on a monthly basis up to 90 days. Findings will be reported at the next quarterly Quality Assurance Committee meeting. All staff will be educated on the definition, importance, and process for the comprehensive plan of care of residents no later than 2/21/2025.
Failure to Investigate Possible Abuse/Neglect Incident
Penalty
Summary
The facility failed to investigate an incident involving possible abuse or neglect of a resident. The incident involved a resident who fell from a Broda chair and sustained a large hematoma on the forehead, along with other symptoms such as dizziness and an upset stomach. The resident was sent to an acute care facility to rule out a head bleed, and upon return, was found to have bruising and fecal smearing. The facility's policy requires immediate reporting and investigation of suspected abuse or neglect, but this was not followed in this case. The resident's care plan included a specific toileting program, which was not adhered to, leading to the fall. The resident had been observed earlier attempting to move forward in the Broda chair and was repositioned by staff. Despite these observations and the fall, the facility did not conduct an investigation into potential abuse or neglect, as confirmed by an interview with a licensed employee. The failure to follow the care plan and the lack of investigation into the incident constitute the deficiency.
Plan Of Correction
The Facility will conduct a review of all current residents in similar situations for which an Electronic Event Report was submitted to the Pennsylvania Department of Health during the period January 9, 2024 to January 9, 2025. The Neglect Screening Tool will be utilized to conduct this review by the Interdisciplinary Team to ensure there were no other instances that required further investigation to determine neglect. Review will be completed no later than 2/28/25. Findings of this audit will be shared with the Facility Quality Assurance Committee at the next quarterly meeting. All staff will be re-educated on Facility Policy and Procedure titled Resident Abuse/Neglect/Misappropriation of Property Prevention (12/23) no later than 2/21/25. The training referenced above will also include discussion of the procedures to follow where, in different situations than this, "neglect" is found, and the subsequent investigations and reporting that must accompany such a finding. A follow-up review of incident and resident 52's medical record was conducted on January 20 -23, 2025 by Administrator, Director of Nursing, Medical Director and members of the Interdisciplinary Team. A Preventative Abuse Incident Monitor will be conducted by NHA or designee to include: Missing Property, Skin Incidents of Unknown Origin and Events Reported to Department of Health involving Abuse, Neglect, Misappropriation. This monitor will include any similar situations involving Event Reports submitted reported to the Pennsylvania Department of Health in which the checklist was utilized. Findings will be reported at the Quarterly QA Committee Meeting.
Inaccurate Resident Discharge Assessment
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident's status for one of the 24 residents reviewed. Specifically, for Resident 58, the discharge Minimum Data Set (MDS) assessment inaccurately indicated that the resident was discharged to an acute hospital. However, a review of the clinical record, including the discharge/transfer summary dated December 5, 2024, revealed that the resident was actually discharged home on that date. This discrepancy was confirmed during an interview with the RNAC, Employee E4, on January 9, 2025, at 11:50 a.m., who acknowledged that the MDS assessment was marked incorrectly.
Plan Of Correction
Upon review of MDS assessment for Resident 58, discharge location was marked in error on Discharge MDS Assessment of Resident 58. Correction was immediately made ("hospital to home") and resubmitted on January 9, 2025, while the surveyor was onsite. RNAC will run "Discharge Register" from EMR on a monthly basis to conduct an audit of discharge MDS and death trackers to confirm accuracy of discharge location. Findings of the audit will be included in the monthly Quality Assurance Documentation Committee report and reported at the quarterly Quality Assurance Committee meeting.
Failure to Timely Notify Physicians of Medication Errors
Penalty
Summary
The facility failed to notify the physician in a timely manner of multiple medication errors experienced by 15 residents. The errors, which were due to inaccuracies from the contracted pharmacy, were identified through internal audits and investigations conducted by the facility. From September 1, 2023, through October 22, 2023, 15 residents experienced 70 medication errors. Despite these findings, the attending physicians were not informed of the errors until December 14 and 15, 2023. This delay in notification was confirmed by the Director of Nursing and the Nursing Home Administrator during interviews on January 22, 2024.
Failure to Address Pharmacy Delivery Errors
Penalty
Summary
The facility failed to identify and address pharmacy delivery errors, resulting in multiple medication errors for 15 residents. These errors were due to the pharmacy delivering medications late, which led to the residents not receiving their prescribed medications on time. The errors included missed doses of critical medications such as Gabapentin, Remeron, Combigan, Latanoprost, Travatan, Saline Nasal Spray, Cosopt, Restasis, Vitamin C, Oyster Shell, Vitamin D3, Vitamin B Complex, Melatonin, Guafenesin, Ferrous Sulfate, Clonazepam, Albuterol, Rytary, Famotidine, Beano, Allegra, Centrum, and Senna. These medications are used to treat various conditions, including pain, appetite stimulation, glaucoma, calcium deficiency, insomnia, iron deficiency, restless leg syndrome, asthma, Parkinson's, nausea, allergies, and constipation. The facility conducted internal audits and investigations, revealing that from September 1, 2023, through October 22, 2023, 15 residents experienced 70 medication errors due to late deliveries from the contracted pharmacy. Interviews with the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the frequency and impact of these errors. Specific instances included multiple missed doses for individual residents, such as R1 not receiving Gabapentin on September 20, 2023, and R2 missing doses of Remeron on three separate occasions. The facility's failure to ensure timely delivery of medications from the pharmacy led to significant medication errors, affecting the health and well-being of the residents. The DON and NHA acknowledged the issue and confirmed that the facility is in the process of finding a new pharmacy to meet the residents' needs. The facility also provided education to nursing staff on medication error policies and conducted pharmacy and medication audits in November and December 2023.
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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