Gardens At Orangeville, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Orangeville, Pennsylvania.
- Location
- 200 Berwick Road, Orangeville, Pennsylvania 17859
- CMS Provider Number
- 395899
- Inspections on file
- 30
- Latest survey
- September 23, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Gardens At Orangeville, The during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a clean and homelike environment, with soiled equipment, stained walls, foul odors, and unaddressed cleaning needs in resident areas. A resident with chronic kidney disease and paraplegia reported her wheelchair was not properly cleaned after an incident, and observations confirmed the presence of residue and damage to the wheelchair. Additional issues included soiled surfaces, odors, and cobwebs in common areas.
Several residents reported a lack of evening activities, expressing interest in options such as card clubs, arts and crafts, movie nights, and bingo after dinner. The activity calendar confirmed that all scheduled activities ended by mid-afternoon, and both the Activities Director and the Administrator acknowledged that no staff were assigned to facilitate evening programs, resulting in unmet resident needs.
Surveyors identified unsanitary conditions in the food and nutrition services department, including a hole in wall grout and accumulated dirt and debris in the kitchen. In a resident pantry area, several food items such as applesauce, canned pears, and milk were found without required date labeling. The FSD confirmed that food items should be dated to ensure safety, indicating a lapse in proper food storage and handling procedures.
A resident with COPD, who was cognitively intact, had $20.00 deducted monthly from her personal needs allowance (PNA) by the facility to pay off a debt, despite Medicaid covering her care costs. The resident was not informed that she was not required to use her PNA for this purpose, and the deductions continued for nearly two years, violating regulations on resident fund management and rights.
A resident with a history of stroke and moderate cognitive impairment, who had a physician order for a soft palm roll to prevent hand contracture, was frequently observed without the device in place and was non-compliant with its use. Staff confirmed the resident often removed the device, and the care plan did not address the resident's limited range of motion or non-compliance with the therapeutic device. The facility was unable to provide documentation of a care plan to address these needs.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
A resident with a PEG tube for enteral feeding was found to have an unlabeled and undated enteral syringe in use, with staff confirming the lack of labeling. Facility policy did not address requirements for labeling, dating, or disposal timeframes for enteral syringes, despite staff expectations. This resulted in a deficiency related to the handling and management of enteral feeding equipment.
A resident's nebulizer machine, including tubing and mask, was not maintained or replaced according to facility policy, with equipment remaining in the room months after treatments were discontinued and lacking proper dating. Staff confirmed the equipment had not been changed as required, and there was no current physician's order for its use.
Surveyors observed persistent musty urine odors in a resident's bathroom and widespread pest issues, including live and dead ants, spiders, centipedes, and other insects throughout a nursing unit. Multiple residents and a representative reported ongoing problems with odors and pests, and an LPN confirmed recurring ant infestations. The NHA acknowledged the facility's responsibility for ensuring a clean and homelike environment.
The facility failed to meet the required NA to resident ratios across multiple shifts, with staffing levels consistently below the required minimums for day, evening, and night shifts. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the shortfall in staffing levels.
The facility did not meet the required LPN to resident ratios on four shifts, with insufficient LPN staffing on the day, evening, and night shifts. No additional higher-level staff were available to compensate for these deficiencies, as confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct resident care per day, falling short on five out of seven days reviewed. Staffing levels were insufficient, with care hours ranging from 2.74 to 3.09 per resident. The Nursing Home Administrator confirmed the shortfall.
A facility failed to administer Torsemide as ordered for a resident with edema, despite documentation of its presence. Additionally, the resident missed a scheduled Pulmonary Medicine appointment due to the facility's failure to arrange transportation, as confirmed by the administrator.
The facility failed to ensure that the director of food and nutrition services, who was not a qualified dietitian, received frequent consultations from a qualified dietitian. The part-time Consultant RD worked remotely and did not have face-to-face interactions with residents or provide direct nutritional oversight. The nursing home administrator could not provide evidence of scheduled consultations between the director and the Consultant RD.
Residents reported significant delays in receiving assistance after ringing call bells, with wait times often exceeding 45 minutes. One resident, with chronic kidney disease and fibromyalgia, highlighted the issue, noting that staff appeared stressed and unpleasant when responding. A group interview revealed similar concerns, with residents experiencing long waits, particularly during low staffing periods, leading to incidents of soiling themselves. The NHA and DON acknowledged the issue but could not provide an explanation for the delays.
The facility did not maintain a clean and homelike environment in two nursing units. Observations included a bathroom with brown stains, a dusty air conditioning unit, a bed with a stained sheet and debris, and a hallway with stained trim and walls. The NHA confirmed the facility's responsibility for cleanliness.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in their clinical records. One resident's assessment inaccurately indicated no anticoagulant medication was received, despite a physician's order for Apixaban. Another resident's discharge status was incorrectly documented as being discharged to a hospital, while the resident was actually discharged home. These inaccuracies were confirmed by facility staff.
A resident with severe cognitive impairment and osteoporosis sustained a laceration during a transfer from bed to wheelchair using a sit-to-stand lift. The injury was discovered after the transfer, and the facility's investigation could not determine the exact cause, though it was suggested the resident's leg might have hit the wheelchair. Both nurse aides involved had satisfactory transfer skills, but the facility failed to implement effective safety measures.
The facility failed to administer IV antibiotics as prescribed for two residents. One resident with chronic osteomyelitis missed multiple doses of Ampicillin and Vancomycin, with no documentation or physician notification. Another resident with a septic knee infection missed a dose of Cefazolin Sodium, also without documentation or notification. The facility's policy requiring eMAR documentation was not followed.
A resident with bipolar disorder and schizoaffective disorder was prescribed Depakote ER 250mg. The consultant pharmacist recommended a gradual dose reduction, but the attending physician did not respond appropriately. Instead, the psychiatric CRNP addressed the recommendation, and the physician cosigned without documenting the rationale for continued use. The DON confirmed the physician's failure to document justification in the clinical record.
A resident with acute respiratory failure and other conditions experienced multiple instances of inadequate nursing care. The resident was found in respiratory distress with low SPO2 levels and was sent to the hospital. Upon readmission, the resident expressed distress and had trouble breathing, but vital signs were not documented. Later, the resident exhibited bradycardia, and increased lung secretions were noted without proper assessment. Eventually, the resident was difficult to arouse with low BP and SPO2, leading to another hospital transfer.
The facility failed to plan menus that accommodate residents' food preferences, leading to dissatisfaction among residents. Despite voicing their preferences during Food Committee meetings, residents felt their input was not considered. A review of the 4-week menu cycle revealed repetitiveness and lack of variety, with beef and poultry served in consecutive meals multiple times. Interviews with the dietary manager and Nursing Home Administrator confirmed these issues.
The facility failed to honor a resident's right to refuse a prescribed therapeutic diet despite the resident being cognitively intact and informed of the risks. The attending physician did not address the resident's wishes for a liberalized diet, and the facility continued to enforce the diet without honoring the resident's decision.
The facility failed to provide adequate housekeeping services, resulting in unsanitary conditions in resident rooms and common areas. Two residents lodged a grievance about the cleanliness of their room, and observations confirmed issues such as a strong smell of urine, soiled rags, sticky floors, and dirty windows. The NHA confirmed that these areas were expected to be clean and sanitary, but the facility did not meet these standards.
The facility failed to ensure that the MDS Assessments accurately reflected a resident's discharge goals. Despite multiple records and staff interviews confirming the resident's wish to return home, the Admission MDS assessment inaccurately indicated that the resident's goal was to remain in the facility.
The facility failed to maintain an environment free of potential accident hazards on the 200-nursing unit. Observations revealed that the hallway from a resident room to 207 was obstructed with mechanical lifts, linen carts, soiled linen and trash hampers, and wheelchairs, blocking access to the corridor handrails intended for resident ambulation or mobility assistance. The Nursing Home Administrator confirmed the obstruction, and the maintenance director measured the distance of the obstructed hallway to be approximately 91 feet.
Failure to Maintain Clean and Homelike Environment Across Nursing Units
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment on both the West and East Nursing Units, as evidenced by multiple observations and resident reports. Specifically, the outer surface and surrounding floor of the ice machine in the East Nursing Unit were visibly soiled, and the wall fabric opposite the ice machine was stained and discolored. The vinyl baseboard molding in the area was also in need of repair. A strong urine-like odor was detected in the Short Hall of the East Nursing Unit, and the floors in a resident room were sticky and tacky, with a foul odor present in both the room and the adjacent hallway. Additionally, a large soiled brief was found in the bathroom sink between two resident rooms. In the dining/activity area of another unit, a buildup of cobwebs was observed behind the counter next to the refrigerator. A resident with chronic kidney disease and paraplegia, who was cognitively intact, reported that after a bowel movement in her wheelchair, staff cleaned her but missed areas of the wheelchair, which remained unclean. Upon inspection, the wheelchair's back support was found to have a rip in the fabric, forming a pocket that contained a thick brown and black residue. The Nursing Home Administrator confirmed that it is the facility's responsibility to provide services to maintain a clean and homelike environment for all residents.
Failure to Provide Evening Activities to Meet Resident Needs
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of residents, specifically by not offering evening activities. During a resident group interview, four out of five residents expressed concerns about the lack of evening activities, with specific requests for the return of a recreation card club, arts and crafts, movie nights, and bingo after dinner. The residents indicated that there was little to do in the evenings and desired more structured activities during that time. A review of the Resident Activity Calendar for the month showed that the latest scheduled activity each day was at 2:00 PM, with no activities planned for the evening. The Director of Activities confirmed that there were no staff scheduled to facilitate evening programs and acknowledged that residents had requested such activities. The Nursing Home Administrator also confirmed the absence of structured evening activities, attributing it to staffing limitations. This lack of evening programming resulted in the facility not meeting the activity needs and interests of its residents.
Unsanitary Food Storage and Handling Practices Identified
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the food and nutrition services department and a resident pantry area, which could lead to food contamination and microbial growth. Specifically, there was a three-quarter inch hole in the wall grout near the handwashing sink, and a build-up of dirt and debris was found along the perimeter of the kitchen and under the tray line counter area. These unsanitary conditions were directly observed during the initial tour with the foodservice director. Additionally, in the resident pantry area on the West Nursing Unit, two four-ounce containers of applesauce, two four-ounce containers of canned pears, and two covered eight-ounce glasses of milk were found without dates indicating when they were available for use. The food service director confirmed that food items were required to be dated to ensure quality and food safety. These findings demonstrate a failure to follow safe food storage and handling practices as required by professional standards and facility policy.
Improper Deduction of Medicaid Resident's Personal Needs Allowance for Facility Debt
Penalty
Summary
The facility failed to protect a resident's personal funds by charging her personal needs allowance (PNA) for services that are covered under Medicaid. The resident, who was cognitively intact and had a diagnosis of chronic obstructive pulmonary disease (COPD), was admitted with a monthly income from which the PNA was deducted, as required by Medicaid regulations. Despite this, the facility deducted an additional $20.00 each month from the resident's PNA to pay off a debt owed to the facility, as agreed upon in a payment agreement signed by the resident. The deductions were made over a period of nearly two years, totaling $460.00, with additional unclear debits also noted in the resident's account. Interviews with the resident and facility staff confirmed that the resident was not informed that she was not obligated to pay her outstanding balance from her PNA funds. The business office manager acknowledged the arrangement and the facility's role as the resident's representative payee, while the nursing home administrator confirmed the ongoing deductions and the lack of documentation showing the resident was properly informed of her rights regarding the use of her PNA. The facility's actions were found to be in violation of state regulations regarding the management of resident funds and resident rights.
Failure to Develop Person-Centered Care Plan for Limited Range of Motion and Device Non-Compliance
Penalty
Summary
The facility failed to develop a person-centered care plan to address a resident's limited range of motion in the left upper extremity and non-compliance with a physician-ordered therapeutic device. The resident, who had a history of cerebrovascular accident (stroke) and depression, was documented to have moderate cognitive impairment and impairment of the left upper extremity. Physician orders and occupational therapy recommendations specified the use of a soft palm roll to the left hand at all times, except during range of motion, hygiene, and skin checks, to maintain skin integrity and prevent further contracture. Despite these orders, observations revealed the resident was frequently found without the soft palm roll in place, and staff confirmed the resident often removed the device using her right hand. Review of the resident's care plan showed it did not address the limited range of motion or the resident's non-compliance with the prescribed soft palm roll. Interviews with staff, including an LPN and the DON, confirmed the resident's non-compliance and the absence of a care plan to address these issues. The Nursing Home Administrator was unable to provide documentation of a care plan that included interventions for the resident's limited range of motion or strategies to address non-compliance with the therapeutic device, resulting in a deficiency under nursing services regulations.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Label and Date Enteral Feeding Syringes
Penalty
Summary
The facility failed to ensure that enteral feeding syringes in use were labeled and dated, and did not provide direction on the maximum time such syringes may remain in service. Observation revealed a 60 mL enteral syringe used for a resident's PEG tube was found on the room windowsill with a clear plastic bag beneath it containing tan residue; neither the syringe nor the bag was labeled or dated. Staff confirmed the syringe was opened but not labeled or dated. Review of the facility's policy showed it did not address labeling, dating, rinsing, or disposal timeframes for enteral syringes, despite staff and administration stating that syringes should be labeled and dated. The resident involved had diagnoses including dysphagia and non-traumatic intracerebral hemorrhage, and required a PEG tube for continuous enteral feeding. Physician orders directed staff to check PEG placement prior to each use and to administer water before and after medications. The lack of labeling and dating of the enteral syringe, as well as the absence of clear policy guidance on the handling and disposal of these syringes, constituted the deficiency identified during the survey.
Failure to Maintain and Remove Respiratory Equipment per Policy
Penalty
Summary
The facility failed to maintain respiratory equipment in accordance with its own Equipment Management Policy for one resident. The policy required that nebulizer machine tubing and masks be changed weekly and as needed to ensure sanitary conditions and safe function. Observation revealed that a nebulizer machine in a resident's room contained tubing and a mask that were not dated to indicate when they were last changed. The nebulizer bowl and tubing were marked with a date from three months prior, and staff confirmed that these items had not been replaced since that time, contrary to facility policy. Further review of the resident's clinical record showed that there was no current physician's order for nebulizer treatments, and the DON confirmed that the resident had previously received treatments earlier in the year, but the equipment was not removed from the room after treatments were discontinued. The respiratory equipment remained in the resident's room and was not maintained as required by policy, as confirmed by staff interviews and record review.
Failure to Maintain Clean and Homelike Environment Due to Persistent Odors and Pest Infestation
Penalty
Summary
The facility failed to maintain a clean and homelike environment on one of its nursing units, as evidenced by multiple observations and resident and staff interviews. In one resident's bathroom, a persistent, strong musty urine odor was noted, with the resident's representative confirming that the smell returns shortly after cleaning and negatively impacts the resident's living experience. Follow-up observation confirmed the odor remained present. Additionally, live and dead insects, including large black ants, spiders, flying insects, centipedes, and worms, were observed throughout the unit's common areas, hallways, and resident rooms. In one resident's room, several large black ants were seen crawling on the bedside table and personal items, and the resident reported that the ants had been present for several weeks, causing frustration and distress. An LPN confirmed the ongoing ant issue and removed contaminated items from the resident's bedside table. Further observations revealed several large spiders with extensive webs, dead ants, a flying insect, and a dead worm near the west exit area. Another resident reported frequently seeing and killing ants in her room, describing them as large black ants. A dead centipede was also found in the unit dining room. The Nursing Home Administrator confirmed the presence of live and dead pests during a subsequent tour and acknowledged the facility's responsibility to maintain a clean and homelike environment for residents.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios across multiple shifts, as evidenced by a review of staffing records. Specifically, the facility did not provide the minimum required number of NAs on the day, evening, and night shifts for 18 out of 21 shifts reviewed. On the day shift, the facility consistently fell short of the required 1:10 NA to resident ratio, with staffing levels ranging from 5.66 to 7.72 NAs for resident censuses between 80 and 83. Similarly, the evening shift did not meet the 1:11 ratio, with staffing levels between 6.06 and 7.16 NAs for the same resident censuses. The night shift also failed to meet the 1:15 ratio, with staffing levels between 3.56 and 4.69 NAs. The deficiency was confirmed through an interview with the Nursing Home Administrator, who acknowledged the facility's failure to meet the required staffing levels. The report does not mention any additional higher-level staff being available to compensate for the staffing shortfall. This consistent understaffing across multiple shifts indicates a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
Facility cannot retroactively correct this deficiency. New scheduling system in place to assist with replacing call offs and filling open shifts via automatic blasts to staff. The new scheduling system also has the ability to post open shifts to all staff including agency. Agency call offs are attempted to be replaced by the agency with additional bonus as needed. Recruitment of nursing staff will continue via facility website, Indeed, recruiting group, social media websites, local newspaper, job fairs, open house and off site recruiters. Agency utilized for open shifts. Retention efforts made with any resignation. Agency rates are reviewed weekly to ensure marketable and adjustments made as necessary. Text Blast for all open shifts. Facility recruiters have purchased list of nursing and aide staff to reach out to for recruitment. New onsite HR Director hired with extensive retention and recruitment experience. Calculation of daily PPD and shift ratios will be completed and reviewed daily for accuracy by the scheduler/back up scheduler, DON/ADON and NHA. All efforts will be made to meet PPD and staffing ratios. If call offs occur, all efforts will be made to attempt to fill that position. Daily PPD and ratios will be audited weekly x4, then monthly x2. Results to QA for review and recommendations.
Failure to Meet LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on four shifts out of 21 reviewed. Specifically, on March 27 and March 29, 2025, the day shift staffing was below the required 1 LPN per 25 residents, with 3.22 and 3.06 LPNs respectively, instead of the required 3.28 for a census of 82. On March 28, 2025, the evening shift had 2.69 LPNs instead of the required 2.73 for a 1:30 ratio, and the night shift had 1.88 LPNs instead of the required 2.05 for a 1:40 ratio. No additional higher-level staff were available to compensate for these deficiencies. The Nursing Home Administrator confirmed the facility's failure to meet the required LPN to resident ratios on these dates during an interview on April 1, 2025.
Plan Of Correction
Facility cannot retroactively correct this deficiency. New scheduling system in place to assist with replacing call offs and filling open shifts via automatic blasts to staff. New scheduling system also has the ability to post open shifts to all staff including agency. Agency call offs are attempted to be replaced by the agency with additional bonus as needed. Recruitment of nursing staff will continue via facility website, Indeed, recruiting group, social media websites, local newspaper, job fairs, open house and off site recruiters. Agency utilized for open shifts. Retention efforts made with any resignation. Agency rates are reviewed weekly to ensure marketable and adjustments made as necessary. Text Blast for all open shifts. Facility recruiters have purchased list of nursing and aide staff to reach out to for recruitment. New onsite HR Director hired with extensive retention and recruitment experience. LPN call outs are the issue with fulfilling this need consistently, so all efforts are made to replace this hole when it occurs. Calculation of daily PPD and shift ratios will be completed and reviewed daily for accuracy by the scheduler/back up scheduler, DON/ADON and NHA. All efforts will be made to meet PPD and staffing ratios. If call offs occur, all efforts will be made to attempt to fill that position. Daily PPD and ratios will be audited weekly x4, then monthly x2. Results to QA for review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident per day. This deficiency was identified through a review of the facility's staffing levels and confirmed by staff interviews. Specifically, on five out of the seven days reviewed, the facility's nursing care hours fell below the required minimum. On March 27, 2025, the facility provided 3.09 hours, on March 28, 2025, 2.74 hours, on March 29, 2025, 2.80 hours, on March 30, 2025, 2.85 hours, and on March 31, 2025, 3.05 hours of direct care per resident. An interview with the Nursing Home Administrator confirmed the facility's failure to consistently meet the required nursing care hours.
Plan Of Correction
Facility cannot retroactively correct this deficiency. New scheduling system in place to assist with replacing call offs and filling open shifts via automatic blasts to staff. New scheduling system also has the ability to post open shifts to all staff including agency. Agency call offs are attempted to be replaced by the agency with additional bonus as needed. Recruitment of nursing staff will continue via facility website, Indeed, recruiting group, social media websites, local newspaper, job fairs, open house and off site recruiters. Agency utilized for open shifts. Retention efforts made with any resignation. Agency rates are reviewed weekly to ensure marketable and adjustments made as necessary. Text Blast for all open shifts. Facility recruiters have purchased list of nursing and aide staff to reach out to for recruitment. New onsite HR Director hired with extensive retention and recruitment experience. Calculation of daily PPD and shift ratios will be completed and reviewed daily for accuracy by the scheduler/back up scheduler, DON/ADON and NHA. All efforts will be made to meet PPD and staffing ratios. If call offs occur, all efforts will be made to attempt to fill that position. Daily PPD and ratios will be audited weekly x4, then monthly x2. Results to QA for review and recommendations.
Failure to Administer Medication and Arrange Transportation
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality for a resident who was admitted with multiple diagnoses, including respiratory failure with hypoxia, COPD, congestive heart failure, and diabetes. A physician order dated December 17, 2024, required the administration of Torsemide, a diuretic, every 24 hours as needed for edema for three days. Despite documentation indicating the presence of edema on multiple shifts between December 17 and December 20, 2024, the medication was never administered. There was no nursing assessment describing the extent or location of the edema, nor was there any evidence that the physician was notified to clarify whether the medication should have been given. Additionally, the resident had a scheduled Pulmonary Medicine appointment on December 23, 2024, which was missed due to the facility's failure to arrange necessary transportation. An interview with the administrator confirmed these deficiencies, indicating that the facility did not ensure the resident received treatment and care in accordance with professional standards of practice and physician orders, potentially impacting the resident's health and well-being.
Deficiency in Nutritional Oversight and Consultation
Penalty
Summary
The facility failed to ensure that the full-time director of food and nutrition services, who was not a qualified dietitian or other clinically qualified nutrition professional, received frequently scheduled consultations from a qualified dietitian or other clinically qualified nutritional professional. The director of food and nutrition services had been employed for four years and had recently completed a course to become a certified dietary manager but had not yet passed the exam. Although the facility employed a part-time Consultant Registered Dietitian (RD) who worked remotely approximately 20 hours per week, there were no frequently scheduled consultations between the director and the Consultant RD. The Consultant RD confirmed that she completed all job tasks, including nutritional assessments, remotely with input from the interdisciplinary team, including nursing and the director of food and nutrition services. However, the Consultant RD did not have face-to-face interactions with residents, did not contact residents by phone before completing nutritional assessments, and had not been in the facility to observe residents' ability to eat or provide nutritional consultation. The nursing home administrator failed to provide documented evidence that the services of the Consultant RD included face-to-face interactions with residents to ensure appropriate nutritional oversight, nor that the director received frequently scheduled consultations from the Consultant RD.
Delayed Response to Resident Call Bells Due to Staffing Issues
Penalty
Summary
The facility failed to provide timely assistance to residents, compromising their quality of life and dignity. Resident 42, who is cognitively intact and suffers from chronic kidney disease and fibromyalgia, reported waiting 45 minutes to an hour for assistance after ringing the call bell, particularly during the second shift. The resident expressed frustration over the long wait times and noted that staff often appeared stressed and unpleasant when they finally responded. This issue was attributed to low nurse staffing, which occurred several times a week. During a group interview, four out of five residents expressed similar concerns about prolonged wait times for assistance. One resident reported waiting over 20 minutes when staffing was low, while another mentioned waiting over an hour, resulting in soiling themselves due to the delay. These residents indicated that the longest wait times occurred in the mornings and afternoons, and they felt the facility was understaffed multiple times a week. The Nursing Home Administrator and Director of Nursing acknowledged that residents should be treated with dignity and respect but could not explain the untimely responses to residents' requests for assistance.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in two out of three nursing units, specifically the 100 and 200 Halls. Observations revealed several deficiencies: a bathroom with brown stains on the floor and doorframe, a window air conditioning unit with a large build-up of dust and black substances, a bed with a stained sheet and debris on the floor, and a hallway with stained and discolored floor trim and wall fabric. These observations were confirmed by the Nursing Home Administrator, who acknowledged the facility's responsibility to provide a clean environment for residents.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their clinical records. Resident 53, who was admitted with a diagnosis of Alzheimer's disease, had a physician's order for Apixaban, an anticoagulant medication, to be administered twice daily. Despite this, the resident's quarterly MDS assessment inaccurately indicated that no anticoagulant medication was received during the 7-day look-back period. This inaccuracy was confirmed by the Registered Nurse Assessment Coordinator (RNAC) during an interview. Similarly, Resident 70's discharge MDS assessment inaccurately documented the discharge status. The assessment stated that the resident was discharged to a short-term general hospital, whereas a discharge note revealed that the resident was actually discharged home, accompanied by her spouse. This discrepancy was confirmed by the Nursing Home Administrator. These inaccuracies in the MDS assessments reflect a failure in the facility's management and nursing services as per the cited Pennsylvania Code regulations.
Failure to Prevent Injury During Resident Transfer
Penalty
Summary
The facility failed to implement effective safety measures to prevent an injury during a transfer for a resident with severe cognitive impairment and osteoporosis. The resident required extensive-to-total assistance with mobility and transfers, as indicated in their care plan. On the day of the incident, the resident sustained a laceration on the right shin during a transfer from bed to wheelchair using a sit-to-stand lift. The injury was discovered after the transfer when blood was noticed on the resident's pants. The facility's investigation could not determine the exact cause of the injury, but it was suggested that the resident's leg might have hit the wheelchair during the initial transfer attempt. The resident was admitted to the emergency department for further evaluation, where the laceration was treated with sutures. Both nurse aides involved in the transfer had satisfactory competency evaluations for transfer skills and knowledge. Despite this, the Nursing Home Administrator confirmed that the facility is responsible for ensuring effective safety measures to prevent such accidents and injuries. The deficiency was identified under the Pennsylvania Code for nursing services and management.
Failure to Administer IV Antibiotics as Prescribed
Penalty
Summary
The facility failed to ensure the proper administration of physician-ordered intravenous antibiotics for two residents. Resident CR1, who was admitted with chronic osteomyelitis of the left ankle and foot, had orders for Ampicillin and Vancomycin to be administered at specific times. However, on multiple occasions, doses of these antibiotics were not administered as scheduled, and there was no documentation of the reasons for the missed doses or notification to the physician. Specifically, on November 10, 2024, two doses of Ampicillin were missed, and on November 13, 2024, a dose of both Ampicillin and Vancomycin was missed. The facility's policy requires documentation in the eMAR system after each medication administration, which was not adhered to in these instances. Similarly, Resident 122, admitted with a septic left knee prosthetic joint infection, had a physician order for Cefazolin Sodium to be administered every eight hours. On November 30, 2024, the 10:00 PM dose was not administered, and there was no documented evidence that the physician was notified of this missed dose. The Nursing Home Administrator confirmed the lack of documentation and adherence to the facility's policy, which mandates that medication administration be documented in the eMAR system to confirm compliance with physician orders.
Failure to Act on Pharmacist's Medication Review
Penalty
Summary
The attending physician failed to act upon pharmacist-identified irregularities in the medication regimen of a resident diagnosed with bipolar disorder and schizoaffective disorder. The resident was prescribed Depakote ER 250mg, a medication used to stabilize mood, and the consultant pharmacist recommended a review for a gradual dose reduction. However, the attending physician did not provide an appropriate response to this recommendation. Instead, the facility's consultant psychiatric CRNP responded to the pharmacy recommendation and signed off on it, while the attending physician merely cosigned without documenting the rationale and justification for the continued use of Depakote. An interview with the Director of Nursing confirmed that the CRNP was handling the pharmacy recommendations and that the attending physician failed to document the justification for the continued use of the medication in the resident's clinical record.
Failure to Timely Assess and Provide Care for Resident
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality for a resident who was admitted with acute respiratory failure, atrial fibrillation, bradycardia, and adult failure to thrive. On one occasion, the resident was found in respiratory distress with a blood oxygen level of 60%, and despite being administered oxygen, the level only increased to 78%. The resident was sent to the hospital for acute respiratory distress and pneumonia. Upon readmission, the resident expressed feeling like he was dying and had trouble breathing, but there were no documented vital signs at that time. Later, the resident exhibited bradycardia, and a stat EKG was ordered. Further documentation revealed that the resident had increased lung secretions, but no vital signs or physical assessment were documented at that time. Eventually, the resident was found difficult to arouse, with low blood pressure and low SPO2 levels, leading to another hospital transfer for acute respiratory failure with hypoxia. The Nursing Home Administrator and Director of Nursing confirmed that the facility staff failed to timely assess and provide care after a change in the resident's condition was noted.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to plan menus that accommodate residents' food preferences, leading to dissatisfaction among residents. This deficiency was identified through a review of the facility's grievance log, interviews with residents and staff, and an examination of the facility's planned menus. Residents B2, B3, B4, and B5 expressed concerns about the lack of variety and repetitiveness in the meals served. Despite voicing their preferences and suggestions during Food Committee meetings, residents felt their input was not considered in the menu planning process. Specific grievances included Resident B2's concern about the lack of variety and Resident B5's complaint about the overuse of eggs at breakfast. Interviews with the dietary manager and the Nursing Home Administrator confirmed these issues, revealing that the facility's cycle menus were developed by the corporate dietitian without adequately considering the residents' preferences. A detailed review of the facility's 4-week Spring/Summer menu cycle further highlighted the repetitiveness and lack of variety in meal planning. For instance, beef and poultry were served in consecutive meals multiple times, and similar meal patterns were observed across different weeks. The dietary manager acknowledged that residents' preferences were not always considered in menu development, and the Nursing Home Administrator confirmed the lack of variety and repetitiveness in the meals. This failure to accommodate residents' food preferences and provide appealing meal options led to dissatisfaction among the residents, as documented in the grievance log and resident interviews.
Failure to Honor Resident's Right to Refuse Treatment
Penalty
Summary
The facility failed to honor a resident's right to participate in their treatment and health care decision-making, including the right to refuse specific treatment. Resident B1, who was cognitively intact with a BIMS score of 15, expressed a desire to refuse the prescribed therapeutic diet despite being informed of the risks by the facility's Registered Dietitian (RD) and Assistant Director of Nursing (ADON). The resident, diagnosed with type two diabetes, cirrhosis of the liver, and major depressive disorder, stated a preference to eat whatever they wanted, acknowledging the risks involved. Despite this, the attending physician did not address the resident's wishes for a liberalized diet, and the facility continued to enforce the therapeutic diet without honoring the resident's decision to refuse it. During an interview with the Nursing Home Administrator (NHA), it was confirmed that the resident was capable of making their own decisions and that the facility failed to honor the resident's right to make informed decisions about their dietary treatment plan. The NHA acknowledged that the attending physician would not agree to liberalizing the diet, despite the resident's continued non-compliance and expressed wishes. This failure to respect the resident's autonomy and right to refuse treatment constitutes a deficiency in the facility's compliance with long-term care regulatory requirements.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to provide adequate housekeeping services to maintain a clean and orderly environment for residents, specifically Residents B2 and B3. A grievance lodged by these residents on March 26, 2024, highlighted concerns about the cleanliness of their room, particularly on weekends. During an interview on April 16, 2024, both residents confirmed that their bathroom was not always cleaned, and the windows and window treatments in their room were very dirty. Observations on the same day revealed a strong smell of urine, a soiled rag on the bathroom floor, sticky floors, and yellow urine-like stains on the base of the toilet. Additionally, several soiled briefs were found in the bathroom garbage receptacle. The windows were heavily coated with a white film, and the window treatments were dusty. Similar cleanliness issues were observed in the west recreation lounge and another resident bathroom, where a pink substance was found in the sink and on the floor, and the base of the toilet had yellow stains. The windows and blinds in this room were also dirty and dusty. An interview with the Nursing Home Administrator (NHA) confirmed that resident rooms, bathrooms, and common areas were expected to be maintained in a clean and sanitary manner. However, the observations and grievances indicate that the facility failed to meet these standards, resulting in an unsanitary living environment for the residents. The findings were in violation of 28 Pa. Code 201.18 (e)(2.1) Management.
Inaccurate MDS Assessment for Resident Discharge Goals
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, Resident 62's Admission MDS assessment inaccurately indicated that her overall goal for discharge was to remain in the facility, despite multiple records and staff interviews confirming her goal was to return home after her therapeutic stay. The resident's clinical record, plan of care, and progress notes all indicated her wish to be rehabilitated and return to her daughter's home. This discrepancy was confirmed through interviews with the Social Services employee and the Nursing Home Administrator.
Obstructed Hallway Creates Accident Hazard
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards and obstacles to safe mobility on the 200-nursing unit. Observations on April 16, 2024, at approximately 10:35 AM and 10:50 AM revealed that the hallway from resident room [ROOM NUMBER] to 207 was obstructed with mechanical lifts, linen carts, soiled linen and trash hampers, and wheelchairs. These items blocked access to the corridor handrails, which are intended for resident ambulation or mobility assistance. The Nursing Home Administrator confirmed the obstruction at approximately 10:55 AM, and the maintenance director measured the distance of the obstructed hallway to be approximately 91 feet at 11:30 AM.
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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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