Edenbrook At Hampton
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilkes Barre, Pennsylvania.
- Location
- 1548 Sans Souci Parkway, Wilkes Barre, Pennsylvania 18702
- CMS Provider Number
- 395249
- Inspections on file
- 33
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Edenbrook At Hampton during CMS and state inspections, most recent first.
Two residents were not protected from abuse by another resident with a known history of aggression and behavioral disturbances. Despite documented incidents of physical aggression, including choking and pushing, and visible injuries, the facility did not provide adequate supervision or substantiate abuse allegations, resulting in repeated harm and emotional distress.
A resident with major depressive disorder was involved in a physical altercation with a roommate, resulting in ongoing emotional distress. Although immediate physical interventions were taken, no social services support was provided to address the resident's psychosocial needs following the incident, as confirmed by staff and documentation review.
Surveyors found that multi-dose insulin pens, including Insulin Lispro and Insulin Glargine, were opened and in use without being dated as required, and one Insulin Glargine pen was used past its expiration date. These issues were confirmed by an LPN and the Nursing Home Administrator, indicating non-compliance with facility policy and state regulations.
Hampton House Rehabilitation and Nursing Center failed to provide a functional, resident-only telephone and ensure privacy for resident phone calls. A resident reported the non-operational phone in the B-Wing Resident Lounge, which had exposed wires and no dial tone, but no maintenance work order was placed to fix it. Additionally, residents had to use a phone behind the nursing station, lacking privacy. This was confirmed by an LPN and the Nursing Home Administrator.
The facility failed to provide adequate staffing and supervision for two residents with dementia, leading to frequent incidents of wandering, aggression, and safety concerns. Despite care plans and interventions, the residents' behaviors persisted, causing fear and discomfort among other residents. Management was unaware of the extent of these issues and could not demonstrate sufficient staffing on the B-Wing.
The facility failed to maintain proper food safety and sanitation practices, as observed during an inspection. The sanitizing solution in the 3-compartment sink was ineffective, and several unsanitary conditions were noted, including splattered ceiling tiles, an overflowing garbage receptacle, and dust and debris on walls and equipment. The Food Service Manager confirmed these deficiencies.
The deficiency involves attending physicians failing to respond to pharmacy recommendations for medication assessments and dose reductions for residents with various diagnoses. Instead, a CRNP signed off on these recommendations, contrary to regulations. The DON confirmed this practice, highlighting a deficiency in the facility's pharmacy and nursing services.
The facility failed to maintain an effective pest control program, with a persistent fly infestation in the A hall nursing unit. Despite ongoing issues for months, the pest control company only began treatment in July and did not provide adequate recommendations for ongoing control. The Nursing Home Administrator confirmed the facility's failure to address the issue effectively.
The facility failed to maintain a clean and safe environment, as observed in a resident's room with soiled tube feeding equipment and dried solution on the floor. Additionally, the medication room had dirt, debris, and a strong mildew smell, while the shower room was infested with sewer flies and had unsanitary conditions. These issues were confirmed by the DON and Nursing Home Administrator.
A facility failed to develop a comprehensive care plan for a resident receiving Eliquis for pulmonary embolism. The care plan did not include the anticoagulant therapy or interventions to monitor for bleeding. This deficiency was confirmed by the NHA and DON, violating 28 Pa. Code 211.12 (d)(5) Nursing services.
The facility failed to accurately monitor the weights of two residents, leading to deficiencies in identifying changes in nutritional parameters. One resident experienced a significant weight loss without timely intervention, while another had fluctuating weights due to inaccurate mechanical lift weighings. The facility did not follow its weight policy or explore alternative weighing methods, impacting nutritional assessments.
A facility failed to create and implement a person-centered care plan for a resident with dementia, who exhibited behaviors like wandering and agitation. The care plan lacked individualized interventions based on the resident's preferences and history, and the facility did not provide necessary non-pharmacological approaches or specialized services to manage the resident's dementia-related behaviors.
A resident with a urinary tract infection did not receive timely antibiotic treatment due to the facility's failure to obtain necessary medication from the pharmacy. The resident's physician was not notified of the missed dose, and the facility did not use its emergency pharmacy services to prevent the delay. The DON confirmed these lapses in protocol.
A facility failed to implement individualized incontinence care for a resident with dementia and muscle wasting. The resident was always incontinent and placed on an Incontinence Care and Comfort plan, but the current care plan did not address their urinary incontinence or include necessary interventions. The facility also failed to document the implementation of the care plan each shift, as confirmed by the DON.
The facility failed to provide detailed written notices for hospital transfers for several residents, lacking correct contact information for appeal assistance and advocacy services. This was confirmed by the Nursing Home Administrator, violating resident rights and licensee responsibilities.
The facility failed to maintain a safe and clean environment in C Hall, with issues such as missing floor molding, exposed wiring, and debris accumulation. Observations included dead bugs in light fixtures, peeling floor molding, and leaking pipes in resident rooms. The Nursing Home Administrator and DON confirmed the need for a safe, clean, and orderly environment.
The facility failed to provide scheduled showers to five residents who required assistance, as documented in June 2024. Despite being scheduled for showers, these residents either did not receive them or were given bed baths without documented preference. The DON confirmed the oversight but could not explain the missed showers, violating nursing services regulations.
A resident with bilateral below-knee amputations was subjected to verbal and mental abuse by a nurse aide during an argument. The aide used derogatory and threatening language, witnessed by other staff, leading to the aide's termination. The facility failed to protect the resident from such abuse, violating resident rights and nursing services regulations.
A resident experienced verbal and mental abuse by a Nurse Aide, which was witnessed by staff but not reported to the State Survey Agency until a week later. The resident, who is cognitively intact, was subjected to threatening and derogatory remarks. Despite the incident, the Nurse Aide continued to work with residents until the abuse was reported and addressed by the facility administration.
The facility failed to investigate an injury of unknown source for a resident with Alzheimer's and osteopenia, and did not promptly address a witnessed incident of verbal and mental abuse by a nurse aide towards a cognitively intact resident with bilateral leg amputations. The aide continued to work with residents for about a week after the incident, and the facility administration could not locate witness statements collected after the abuse.
A resident with cognitive intactness and a history of polyosteoarthritis and bilateral below-knee amputations was verbally and mentally abused by a nurse aide. Despite the incident being witnessed by staff and the aide's eventual termination, the facility failed to assess the resident for psychosocial harm or provide supportive services. The resident expressed fear and distress, and the Director of Social Services confirmed the lack of documentation for any supportive visits or assessments.
A sit-to-stand lift in the residents lounge area was found to be malfunctioning, with the left leg of the base not moving when activated by the electronic controller. This issue was observed in the presence of the DON, who confirmed the facility's failure to maintain the equipment in a safe operating condition.
A resident with severe cognitive impairment and multiple diagnoses developed pressure ulcers due to the facility's failure to implement a positioning schedule, use pressure-reducing devices, and apply barrier creams as per policy. The DON confirmed the lack of consistent preventive measures.
The facility failed to administer pain medication as prescribed and did not attempt non-pharmacological interventions for a resident with severe pain. Despite the resident's complaints and the ineffectiveness of the medications, the facility did not follow its policy to notify the physician or attempt alternative pain relief methods. The DON confirmed these deficiencies.
Failure to Prevent Resident-on-Resident Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents from abuse by another resident with a known history of physical aggression. Resident 82, who had diagnoses including dementia with behavioral disturbance and anxiety, exhibited aggressive behaviors such as intrusive wandering and physical aggression. Despite these known risks, the facility did not maintain adequate supervision or implement sufficient interventions to prevent Resident 82 from physically assaulting other residents. The first incident involved Resident 82 placing his arms around the neck of another resident in the television lounge, which was witnessed by staff and resulted in staff intervention. Following this initial event, Resident 82 continued to display aggressive behaviors, including yelling, cursing, and unsuccessful redirection attempts by staff. A second incident occurred when Resident 82 grabbed another resident by the neck and pushed him, resulting in visible redness on the resident's neck. This incident was reported by the victim and corroborated by staff documentation, yet the facility did not substantiate the abuse allegation, citing a lack of direct staff witnesses despite physical evidence and consistent resident statements. The facility's failure to provide consistent and adequate supervision for Resident 82, despite his documented history of aggression and psychiatric recommendations, led to repeated incidents of physical aggression and emotional distress for other residents. The facility also failed to substantiate abuse allegations in the presence of physical signs of injury and credible witness statements, further contributing to the deficiency.
Failure to Provide Social Services After Resident Altercation
Penalty
Summary
A resident with a diagnosis of major depressive disorder and a BIMS score indicating cognitive intactness was involved in an altercation with a roommate, during which the roommate grabbed the resident's throat. Facility documentation confirmed physical evidence of the incident, including redness on the resident's neck, and immediate interventions were implemented to separate the residents and change rooms. Despite these actions, the resident continued to experience distress and requested support in managing his emotional response to the incident, including education from a psychiatric provider. However, interviews with facility staff and review of the clinical record revealed that no social services intervention or visit was provided to address the resident's psychosocial needs following the altercation. Both the social services staff member and the Nursing Home Administrator confirmed the absence of documented social services support for the resident after the incident, resulting in a failure to provide medically-related social services to help the resident achieve the highest possible quality of life.
Failure to Properly Label and Store Multi-Dose Insulin Pens
Penalty
Summary
The facility failed to comply with accepted standards for the labeling and storage of multi-dose medications, as observed during a review of a medication cart on the C Hall unit. Specifically, one multi-dose insulin pen of Insulin Lispro and two multi-dose pens of Insulin Glargine were found opened and in use without being labeled with the date they were initially opened, contrary to facility policy and manufacturer guidelines. Additionally, one Insulin Glargine pen was labeled with an opening date but was still in use past its recommended 28-day discard date. These deficiencies were confirmed through observation in the presence of an LPN and further verified during interviews with both the LPN and the Nursing Home Administrator. The facility's own policy requires opened multi-use vials or bottles to be dated to ensure proper tracking for expiration, and manufacturer instructions specify discard timelines for insulin pens. The failure to date and timely discard these medications resulted in non-compliance with state pharmacy and nursing service regulations.
Deficiency in Resident Communication Privacy and Access
Penalty
Summary
Hampton House Rehabilitation and Nursing Center was found to be non-compliant with federal and state regulations regarding residents' rights to communication privacy and access. The facility failed to provide a functional, resident-only telephone for a resident in the B-Wing Resident Lounge, as the phone was non-operational with exposed wires and no dial tone. This issue was reported by the resident during a Resident Council Meeting, but no action was taken to address the concern, as evidenced by the absence of a maintenance work order to repair the phone. Additionally, the facility did not ensure privacy for residents making telephone calls. Residents were required to use a landline telephone located behind the nursing station, which did not provide privacy as it was positioned on the counter, necessitating residents to sit in front of the nursing station during calls. This arrangement was confirmed by a licensed practical nurse and the Nursing Home Administrator, who acknowledged the lack of privacy and access to a functional, resident-only telephone, impacting residents' ability to communicate confidentially and independently.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. FTAG 576- Rights to forms of Communication with Privacy- B lounge not working. 1. B wing Resident Lounge Phone fixed immediately. 2. January 2025 Resident council minutes were reviewed to ensure any concerns documented were resolved. 3. 3 cordless phone devices were purchased for each of the nursing units providing access to additional functional, resident-only telephones. Cordless phones to be utilized by residents in their resident room allowing for privacy, confidentiality and independent communications. 4. NHA/Designee will provide education to current staff regarding Resident's Right to Forms of Communication with Privacy. 5. NHA/Designee will conduct weekly audits x4 and then monthly x3 to ensure all Resident-only telephones are appropriately working. Results of the audits will be reviewed at the facility QA meeting. 6. NHA/Designee will conduct monthly audit x3 to ensure all monthly resident council documented concerns have work orders and work orders are addressed and appropriately resolved. Results of the audits will be reviewed during facility QA meeting. 7. Date of Compliance March 7, 2025.
Inadequate Staffing and Supervision of Residents with Dementia
Penalty
Summary
The facility failed to provide sufficient staff with the necessary competencies and skills to manage and supervise the wandering and aggressive behaviors of two residents, identified as Residents 4 and 20. Resident 4, admitted with dementia and violent behavior, exhibited frequent incidents of wandering into other residents' rooms, exit-seeking behaviors, and aggression towards staff and other residents. Despite interventions outlined in the resident's care plan, such as 15-minute checks and redirection, these behaviors persisted, leading to a subacute fracture of the resident's left foot, raising concerns about the adequacy of supervision. Resident 20, also admitted with dementia, displayed similar behaviors, including wandering into other residents' rooms, verbal aggression, and physical aggression, such as attempting to strike staff members with a cane. The care plan for Resident 20 included interventions like the use of a wander guard system and calm redirection, but these measures were insufficient to manage the resident's behaviors effectively. Interviews with residents and staff revealed that the presence of Residents 4 and 20 caused fear and discomfort among other residents, with reports of intrusions into personal spaces and aggressive encounters. The facility's management, including the Nursing Home Administrator and Director of Nursing, were unaware of the extent of these behavioral incidents and could not provide evidence of sufficient staffing with appropriate skills on the B-Wing. Interviews with staff indicated that the facility did not assign enough personnel to manage the behaviors and conduct the required checks, leading to repeated incidents of resident-on-resident intrusions and safety concerns.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. FTAG 741- Sufficient/Competent Staff-Behavioral Health Needs- supervision and safety of residents. 1. Facility unable to retroactively correct sited deficient practice. 2. Identified behavioral residents, residents #4 and #20, to be assessed and evaluated with Behavioral Health Services. 3. Identified residents #4 and #20 current recreational activity plan of care to be reviewed and evaluated. Based on additional needs identified, recreational activity schedule to be adjusted to meet needs of residents. 4. 30 day-look back of current facility residents with diagnosis of Dementia reviewed for any repeated incidents of resident-on-resident, intrusions, aggressive behaviors, and safety concerns. 5. Residents identified with repeated behavior will be assessed and evaluated with Behavioral Health Services. 6. Current staff will be educated on meeting the needs of behavioral residents. 7. Recreational Activity will assess identified residents and implement resident centered activities program. 8. Clinical team will review previous day incident reports involving identified residents related to behavioral health to ensure interventions meet identified residents' behavioral health needs. 9. NHA/Designee will conduct weekly audits x4 then monthly audits x2 to ensure behavioral health needs are being met clinically and socially. 10. Results of audits will be reviewed during facility QA meeting. 11. Date of Compliance March 7, 2025.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an inspection, it was observed that the sanitizing solution in the 3-compartment sink was ineffective, with a test strip indicating zero parts per million of sanitation solution, contrary to the required 200-400 PPM. The Food Service Manager confirmed the deficiency and was unsure why the solution was so weak. Additionally, several unsanitary conditions were noted, including splattered ceiling tiles, an overflowing garbage receptacle without a lid, and dust and debris on walls and equipment. Further observations revealed that the exhaust hood over the stove had discolored rags stuck in it, and a container labeled for hard-boiled eggs was cracked, exposing its contents to potential contamination. The hosing attached to the water filter and coffee maker was heavily corroded with dust and debris. These conditions were confirmed by the Food Service Manager, who acknowledged that the kitchen areas should be maintained in a sanitary manner to prevent contamination and foodborne illness.
Failure of Attending Physicians to Respond to Pharmacy Recommendations
Penalty
Summary
The deficiency involves the failure of attending physicians to act upon pharmacist-identified irregularities in the medication regimens of several residents. The report highlights that the attending physicians did not provide appropriate responses to pharmacy recommendations for medication assessments and potential dose reductions. Instead, the facility's consultant psychiatric CRNP responded to these recommendations, which is not in accordance with the regulations requiring the attending physician's involvement. The report details specific cases involving four residents with various diagnoses, including bipolar disorder, depressive disorder, mood disorder, and dementia. For each resident, the consultant pharmacist made recommendations regarding the evaluation of psychopharmacological medications and the need for gradual dose reductions or specific rationales if dose reductions were not indicated. However, the attending physicians failed to document individualized responses, and the CRNP signed off on the recommendations instead. The Director of Nursing confirmed that the CRNP was responding to the pharmacy recommendations rather than the attending physicians, as required by regulation. This failure to comply with the regulatory guidelines for medication regimen reviews and physician responses constitutes a deficiency in the facility's pharmacy and nursing services, as well as the oversight by the medical director.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by observations and staff interviews. A strong mildew and sewage smell was detected in the A hall nursing unit medication room, along with the presence of a flying bug. In the A hall nursing unit shower room, a significant infestation of sewer flies was observed, with flies covering the walls, tub, and shower stalls, and numerous dead flies on the floor. An LPN confirmed that the bug issue had persisted for at least four months and worsened over the summer, affecting both the shower and medication rooms. The pest control company contracted by the facility did not begin treating the fly infestation until July 9, 2024, despite the problem being ongoing for months. The pest control reports indicated treatments were applied, but no recommendations were provided to the facility for ongoing drain treatments to control the flies between visits. Subsequent reports showed the treatments were ineffective, and the pest control company failed to offer specific sanitation or treatment recommendations. The Nursing Home Administrator confirmed the facility's failure to implement necessary measures for effective pest control.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by multiple observations of unsanitary conditions. On August 20, 2024, it was observed that in Room B14, a resident's tube feeding pump and pole were soiled with dried tube feeding solution, and there were dried spots of the solution on the floor. This issue persisted, as a subsequent observation on August 23, 2024, revealed that the dried solution remained on the pump, pole, and floor. Additionally, on August 22, 2024, the A hall nursing unit medication room was found to have dirt and debris on the floor, accompanied by a strong mildew and sewage smell. A flying bug was also observed in the room. The A hall nursing unit shower room was noted to have a large number of sewer flies covering the walls, with multiple dead flies on the floor, in the tub, and splattered on the walls. Wet clumps of paper were found on the floor, and the shower curtain had brown stains. Cracked tiles were observed on the wall near the floor. These conditions were confirmed by the Director of Nursing and the Nursing Home Administrator, who acknowledged the facility's responsibility to maintain a clean and sanitary environment daily.
Failure to Develop Comprehensive Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop a person-centered care plan that included individual medication therapy for a resident. Resident 12, who was admitted with a diagnosis of hypertension, was receiving Eliquis, an anticoagulant medication, twice a day for a history of pulmonary embolism. However, the resident's care plan did not identify the anticoagulant therapy or include interventions to monitor for bleeding. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged that comprehensive care plans were not developed for the resident. The failure to include the necessary medication therapy and monitoring interventions in the care plan was a violation of 28 Pa. Code 211.12 (d)(5) Nursing services.
Failure to Monitor Resident Weights Accurately
Penalty
Summary
The facility failed to consistently and accurately monitor resident weights, leading to deficiencies in identifying changes in nutritional parameters for two residents. Resident 40 experienced a significant weight loss of 19.9% over 30 days, dropping from 167 lbs to 133 lbs. Despite the Registered Dietitian (RD) questioning the accuracy of the weight, a reweigh confirmed the loss, yet no new interventions were implemented until weeks later. The resident's nutritional care plan had not been updated since April, despite the significant weight change. Resident 91, who was NPO and required a feeding tube, also experienced issues with weight monitoring. The resident's weight fluctuated significantly due to jerky movements during mechanical lift weighings, leading to inaccurate weight records. Despite a significant weight loss of 16.2 pounds in less than a week, the facility did not obtain a timely re-weight within the 72-hour policy window. The RD noted the weight changes but did not recommend new interventions, as the tube feeding was deemed adequate. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the facility's failure to follow its weight policy. The facility did not explore alternative methods for obtaining accurate weights for dependent residents, impacting the ability to perform accurate assessments of nutritional requirements. This lack of timely and accurate weight monitoring led to deficiencies in the care provided to these residents.
Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an effective individualized person-centered care plan for a resident diagnosed with dementia, leading to a deficiency. The resident, who was admitted with a diagnosis of dementia and was severely cognitively impaired, exhibited behaviors such as intrusive wandering, striking out, screaming, and agitation over several months. Despite these behaviors, the resident's care plan did not address their dementia diagnosis or include individualized interventions tailored to their preferences, social history, customary routines, and interests. The facility did not provide evidence of necessary care and services, including interdisciplinary non-pharmacological approaches, purposeful activities, or environmental modifications to manage the resident's dementia-related behaviors. An interview with the Nursing Home Administrator confirmed the absence of an individualized person-centered plan to address these behaviors. The facility's failure to provide specialized services and supports, such as activities, nutrition, and environmental modifications, based on the resident's abilities and dementia-related behaviors, was noted as a deficiency.
Failure to Administer Timely Antibiotic Treatment
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not ensuring timely administration of physician-ordered medication for a resident with a urinary tract infection. Resident 93, who was admitted with diagnoses including Guillain-Barre Syndrome, neuromuscular dysfunction of the bladder, and urine retention, had a confirmed urinary tract infection based on urine culture results received on July 24, 2024. Despite new orders for the antibiotic Ceftriaxone to be administered intramuscularly for seven days, the medication was not given on July 27, 2024, due to the facility waiting for Lidocaine from the pharmacy. The clinical record did not show that the resident's physician was notified of the missed dose, and the facility did not utilize its contracted emergency pharmacy to prevent the delay in treatment. Interviews with the Director of Nursing confirmed these failures, highlighting that the nursing staff did not implement emergency provisions to contact the emergency pharmacy, resulting in a delay in the administration of the prescribed antibiotic therapy.
Failure to Implement Incontinence Care Plan
Penalty
Summary
The facility failed to implement individualized approaches for incontinence care for one resident, identified as Resident 25. The facility's policy on Urinary and Bowel Incontinence Evaluation and Management, last reviewed in April 2024, requires residents not suitable for a toileting schedule to be placed on an Incontinence Care and Comfort plan, which involves checking and changing every two to three hours. Resident 25, who was admitted with diagnoses including dementia and muscle wasting, was always incontinent of bowel and bladder and had poor potential for a toileting schedule. However, the resident's current plan of care did not identify their urinary incontinence or include interventions to provide necessary care and services. Additionally, the facility failed to document that the incontinence care and comfort plan was being implemented and completed each shift for Resident 25. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the failure to provide maintenance care to the resident.
Deficient Transfer Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide sufficiently detailed written notices of facility-initiated transfers to the hospital for seven residents. The written notices lacked the correct address and phone number for assistance with the appeal process and the correct contact information for the advocacy of persons with disabilities and mental health. This deficiency was identified during a review of the clinical records of the affected residents, who were transferred to the hospital on various dates between April and August 2024. The Nursing Home Administrator confirmed during an interview that the information provided to the residents was incorrect. The facility's failure to provide accurate and complete transfer notices violated resident rights and the responsibility of the licensee as outlined in 28 Pa. Code 201.29(h) and 28 Pa. Code 201.14(a).
Facility Fails to Maintain Safe and Clean Environment in C Hall
Penalty
Summary
The facility failed to maintain a safe, clean, and orderly environment in one of its resident units, specifically C Hall. Observations revealed several deficiencies, including a missing floor strip molding at the nursing station, which left a hole filled with rocks, dirt, metal, and other debris. Additionally, an ethernet outlet cover was detached, exposing interior wiring, and there were issues with phone wires. In the resident shower room, dead bugs and debris were found inside a ceiling light fixture, and a thick layer of dust covered the ceiling vent and fan blades. Further observations in various resident rooms highlighted additional issues. In room C-16, floor molding was peeling, revealing dark discoloration, and trash such as a banana peel and food wrappers were found on the floor. Room C-3 had peeling floor molding with surrounding stains and dirt on the bathroom floor. Room C-13 had trash and debris on the floor, while room C-9 had a missing name identification plate and a continuously running toilet. Room C-17 had a leaking pipe under the bathroom sink. In the resident lounge, a lift-to-stand device was found with frayed and peeling medical tape. These observations were confirmed by the Nursing Home Administrator and Director of Nursing, acknowledging the need for a safe, clean, and orderly environment.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for assistance with activities of daily living were consistently provided showers as planned. This deficiency was identified for five out of ten residents sampled. Resident B1, who was cognitively intact and required substantial assistance for showering, reported not receiving scheduled showers on two occasions in June 2024. The facility's documentation confirmed the absence of showers on these dates without any record of refusal by the resident. Similarly, Resident B2, who required supervision for showering, did not receive scheduled showers on two occasions in June 2024. The facility's records did not indicate any refusal by the resident. Resident B3, who was newly admitted, reported not being offered a shower since admission, and the facility's documentation showed missed showers with no applicable reason provided. Resident B4, requiring maximal assistance, received bed baths instead of showers on two occasions, with no documentation of preference for bed baths. Resident B5, who required total assistance, also received bed baths instead of showers on two occasions, with no documented preference for bed baths. The Director of Nursing confirmed that the residents should have been showered as scheduled and was unable to explain why the showers were not provided. The facility's failure to provide showers as planned violated the nursing services regulation, specifically 28 Pa. Code 211.12 (d)(5).
Resident Subjected to Verbal and Mental Abuse by Staff
Penalty
Summary
The facility failed to protect a resident, identified as Resident A1, from verbal and mental abuse by a staff member, Employee 3, a nurse aide. The incident occurred on June 8, 2024, when Resident A1, who is cognitively intact and has bilateral below-knee leg amputations, confronted Employee 3 outside the nursing station. The confrontation escalated into an argument where Employee 3 used derogatory and threatening language towards Resident A1, including statements about his amputations and threats of harm. Multiple staff members witnessed the altercation, including Employee 5, another nurse aide, and Employee 4, a registered nurse, who intervened to separate the parties. Employee 5 reported hearing Employee 3 use profanities and make threats towards Resident A1, while Employee 4 confirmed that he had to physically prevent Employee 3 from approaching Resident A1 further. The altercation was characterized by yelling and the use of abusive language by Employee 3, which was corroborated by witness statements and interviews conducted during the investigation. The facility's investigation concluded that Employee 3's actions constituted mental abuse, as defined by the facility's policy on abuse. The Director of Nursing and the Nursing Home Administrator acknowledged the failure to protect Resident A1 from such abuse, confirming that Employee 3 was suspended and subsequently terminated following the incident. The deficiency was identified as a violation of resident rights and nursing services regulations.
Failure to Timely Report Resident Abuse
Penalty
Summary
The facility failed to timely report the witnessed abuse of a resident, identified as Resident A1, to the State Survey Agency. The incident involved Employee 3, a Nurse Aide, who made threatening and derogatory statements to Resident A1, which met the definition of mental and verbal abuse. The abuse occurred on June 8, 2024, but was not reported to the State Survey Agency until June 15, 2024, seven days after the incident. This delay in reporting violated the facility's abuse prohibition policy, which mandates immediate reporting of abuse allegations. Resident A1, who is cognitively intact with a BIMS score of 15, was involved in an altercation with Employee 3 outside the nursing station. During the argument, Employee 3 made threatening remarks, including telling Resident A1 that he would end up dead and using derogatory language. Witnesses, including Employee 4, a Registered Nurse, and Employee 5, a Nurse Aide, confirmed the altercation and the abusive language used by Employee 3. Despite the severity of the incident, Employee 3 continued to work with residents for the remainder of the shift and was not suspended until a week later. The facility's administration, including the Director of Nursing and the Nursing Home Administrator, acknowledged the failure to report the abuse within the required timeframe. They were unable to provide the surveyor with the statements that Employee 4 claimed to have submitted on the day of the incident. The delay in addressing the abuse and the continued employment of Employee 3 with resident contact until June 15, 2024, highlights the facility's failure to adhere to its own policies and federal and state regulations regarding the timely reporting of abuse.
Failure to Investigate and Protect Residents from Abuse
Penalty
Summary
The facility failed to timely and thoroughly investigate an injury of unknown source for Resident CR1, who was admitted with Alzheimer's disease and osteopenia. The resident was found with a tibia-fibula fracture, and the facility did not conduct a thorough investigation to rule out potential abuse, neglect, or mistreatment. Employee 3, a nurse aide, documented providing care to the resident without assistance, contrary to the resident's care plan, but the facility did not identify this discrepancy in their investigation. Additionally, the facility failed to promptly investigate a witnessed incident of verbal and mental abuse by Employee 3 towards Resident A1, who was cognitively intact and had bilateral below-knee leg amputations. Employee 3 made threatening and derogatory statements to Resident A1, and despite the incident being witnessed by other staff, the facility did not immediately remove Employee 3 from resident care. Employee 3 continued to work at the facility and interact with residents, including Resident A1, for about a week following the incident. The facility's administration was unable to locate witness statements collected by Employee 4, RN, following the abuse incident involving Resident A1. The Director of Nursing and Nursing Home Administrator confirmed that the facility failed to protect residents from potential further abuse by allowing Employee 3 to continue working with residents after the incident. Employee 3 was not suspended until several days later, after another employee reported concerns to the facility administration.
Failure to Provide Social Services After Resident Abuse
Penalty
Summary
The facility failed to provide necessary therapeutic social services to a resident following an incident of verbal and mental abuse by a staff member. The resident, who was cognitively intact and had a history of polyosteoarthritis and bilateral below-knee amputations, was subjected to threatening and derogatory statements by a nurse aide. This incident was witnessed by other staff members, and the nurse aide was eventually terminated. However, the facility did not assess the resident for psychosocial harm or provide any documented supportive visits after the incident. The altercation occurred when the resident confronted the nurse aide, leading to an argument where the aide made threatening remarks. Despite the intervention of a registered nurse who witnessed the incident, the nurse aide continued to work at the facility for a week following the altercation, even entering the resident's room. The resident expressed fear and distress, staying up late during the aide's shifts due to concerns for his safety. Interviews with staff confirmed the details of the incident and the lack of immediate action by the facility administration. The Director of Social Services acknowledged that there was no documentation of any assessment or supportive services provided to the resident after the abuse. This lack of action and documentation highlights the facility's failure to meet regulatory requirements for providing adequate social services to address the resident's mental and psychosocial well-being after the incident.
Sit-to-Stand Lift Malfunction
Penalty
Summary
The facility failed to ensure that essential resident care equipment, specifically a sit-to-stand lift, was in safe operating condition. During an observation in the second floor B wing residents lounge area, it was noted that one out of three sit-to-stand lifts was not functioning properly. The adjustable leg base of the lift, which is designed to extend open to accommodate various positions and provide a wider base of support during resident transfers, had a malfunctioning left leg that would not move when activated by the electronic controller. This issue was confirmed during an interview with the Director of Nursing (DON), who acknowledged the facility's failure to maintain the equipment in a safe operating condition.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to promptly act upon known risk factors for pressure sore development and did not timely implement individualized measures to prevent pressure sores and promote healing for a resident. The resident, who had severe cognitive impairment and required extensive assistance with bed mobility and transfers, was identified as being at risk for skin breakdown. Despite this, there was no evidence of the implementation of a positioning schedule, utilization of pressure-reducing wedges or pillows, or application of barrier creams according to the facility's policy during January and February 2024. The resident was admitted with multiple diagnoses, including a fracture of the right femur, reduced mobility, and moderate protein-calorie malnutrition. The care plan included interventions such as encouraging good nutrition and hydration, using prevalon boots, and providing a bariatric specialty mattress and chair pad. However, the facility did not consistently implement these measures. The resident developed a purple area on the right heel and later an unstageable pressure ulcer on the buttocks, indicating a failure to follow the planned interventions. The Director of Nursing confirmed that the facility could not demonstrate the consistent implementation of measures to prevent pressure ulcers and promote healing. The resident's condition worsened, resulting in a deep tissue injury and an unstageable pressure ulcer. The facility's failure to adhere to its policies and procedures for skin integrity and pressure ulcer prevention led to the resident's deteriorating condition.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to administer pain medication as prescribed by the physician and did not attempt non-pharmacological interventions to alleviate pain for Resident D2. The resident, who was readmitted to the facility with multiple diagnoses including a hip fracture, rheumatoid arthritis, and a dislocated kneecap, frequently experienced severe pain that was not effectively managed by the prescribed medication regimen. Despite the resident's complaints of severe pain and the ineffectiveness of the administered medications, there was no evidence that the facility attempted non-pharmacological interventions or notified the physician about the inadequacy of the pain management plan. The resident's Medication Administration Record (MAR) indicated that while the scheduled Morphine Sulfate was administered as ordered, the as-needed Oxycodone and Tramadol were often ineffective in managing the resident's pain. The facility's policy required non-pharmacological interventions and physician notification if the pain regimen was ineffective, but these steps were not documented or followed. The Director of Nursing confirmed that the facility did not provide effective pain management, did not consistently attempt non-pharmacological interventions, and failed to notify the practitioner as required by the facility's policy.
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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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