Gardens At Stevens, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Stevens, Pennsylvania.
- Location
- 400 Lancaster Avenue, Stevens, Pennsylvania 17578
- CMS Provider Number
- 395575
- Inspections on file
- 28
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Gardens At Stevens, The during CMS and state inspections, most recent first.
The facility did not complete or document required annual performance reviews for five nurse aides. Review of personnel files showed no evidence of performance evaluations within a 12‑month period, and the Nursing Home Administrator confirmed that there was no documentation of these reviews, in violation of state personnel policy requirements.
Surveyors found that multiple nurse aides had no documented completion of the required 12 hours of annual in‑service education, including dementia care and abuse prevention content. Review of several personnel files showed an absence of records demonstrating that these staff had met the annual training requirement, and the NHA confirmed that there was no evidence that the mandated in‑service hours had been completed.
Surveyors identified that insulin pens on two medication carts were not managed according to professional standards. On one cart, an open Toujeo insulin pen lacked an expiration date, and an unopened Toujeo pen was not kept refrigerated per manufacturer instructions. On another cart, an open Lantus insulin pen had no open or expiration date, and an unopened Lantus pen was also stored unrefrigerated. The DON confirmed that these insulin pens were not properly labeled or stored.
Surveyors found that the facility did not notify the State LTC Ombudsman when several residents were transferred to the hospital for evaluation or admission, as documented in nursing progress notes and confirmed by the NHA, DON, and Social Services. In addition, for a resident who had a planned discharge to home, the MDS and nursing notes showed the discharge occurred, but the facility did not complete the required discharge summary with a recapitulation of the resident’s stay. These failures were cited under state regulations governing the licensee’s responsibilities.
A resident’s quarterly MDS assessment was inaccurately coded to show use of an anticoagulant in the high-risk drug class section, despite clinical record review of physician orders and the MAR confirming that no anticoagulant had been ordered or administered during the lookback period. An interview with licensed staff confirmed the miscoding of the assessment, resulting in an inaccurate clinical record.
A resident was not invited, nor was the resident’s representative invited, to participate in interdisciplinary care plan meetings. Record review showed no documentation of any invitation to care plan meetings, and the resident reported never being asked to attend such a meeting. The NHA confirmed there was no evidence that the resident or representative had been invited to participate in the care planning process, resulting in a violation of resident rights and nursing services requirements.
Two residents did not receive care according to provider orders and standards. One resident with metastatic lung cancer received decadron as ordered in preparation for a chemotherapy infusion, but the infusion appointment was missed because transportation was not arranged, and the steroid regimen was then discontinued. Another resident with a scheduled cataract surgery had an active NPO order and a diet communication sent to the kitchen, yet still received and ate a breakfast tray, leading to cancellation of the surgery. These events were confirmed by facility leadership, including the NHA and DON.
A resident with chronic pain conditions did not have their Fentanyl transdermal patch changed as ordered by the physician, resulting in unaddressed pain despite notifying nursing staff. Review of medication records confirmed the patch was not removed and reapplied as scheduled, and the NHA acknowledged improper medication administration.
Staff interviews revealed that 1-2 residents are unable to attend scheduled Sunday religious services each week because nursing staff do not assist them out of bed in time. The Activities Director and Assistant reported this occurs every weekend and did not inform the NHA. A resident confirmed missing a service due to not being assisted out of bed before the scheduled time.
A resident diagnosed with scabies was not placed on contact precautions as required by facility policy. There were no physician orders for contact precautions, and no signage was present in the resident's room. The ADON was unaware of the diagnosis and confirmed that precautions should have been implemented.
Surveyors found that several residents, including those with cognitive impairment and those requiring moderate to total assistance, did not receive scheduled showers and were instead given bed baths without documentation that showers were offered. Interviews and observations revealed residents were unkempt, dissatisfied with their hygiene care, and that staff shortages contributed to missed showers. The DON and administrator confirmed the lack of documentation for showers on the scheduled days.
Several residents did not receive scheduled showers over an extended period, despite not refusing care, due to insufficient nursing staff. Residents were observed to be unkempt and reported being told that staff shortages prevented them from receiving showers. Staff interviews confirmed that inadequate staffing led to missed showers and incomplete daily care.
Surveyors identified that clinical records for several residents, including those with cognitive impairments and chronic conditions, were incomplete or inaccurately documented. Multiple shower records were left blank or marked as 'NA,' which the DON confirmed was not acceptable practice. These documentation lapses were found across several months and affected residents who required varying levels of assistance with personal care.
The facility did not have a system in place to track and monitor infectious skin conditions, as confirmed by interviews with the infection prevention nurse, DON, and nurse practitioner. Two residents were observed with rashes, one of whom received permethrin cream after other treatments failed, but no scabies testing was performed. Staff interviews revealed confusion over responsibility for tracking and trending skin conditions.
The facility did not complete required investigations into two separate incidents involving residents—one with cognitive impairment and another who was cognitively intact and dependent on staff—where concerns of possible abuse or neglect arose. In both cases, there was no documentation of an investigation or collection of written statements from those involved, despite policy requirements.
A cognitively impaired resident with Alzheimer's and dementia did not receive a required RN assessment after a male resident was found in her bed. The incident was reported by the resident's daughter, and facility leadership confirmed that no RN assessment was documented as required by policy.
The facility failed to ensure that common wall doors positively latched on both floors within the component. Observations revealed that the doors did not latch properly at specific locations on the upper and lower levels between Components 01 and 02. The Director of Maintenance confirmed this issue.
The facility did not maintain stair tower doors within the allowed gap margins on one of two floors, as observed and confirmed through interviews. This failure to adhere to NFPA 101 standards for stairways and smokeproof enclosures as exits was noted during the survey.
The facility failed to maintain corridor doors, with observations revealing that stairtower doors near a resident room had excessive gaps, and corridor doors to two resident rooms failed to close and latch. These issues were confirmed by the Director of Maintenance, indicating non-compliance with NFPA 101 standards for fire safety and smoke containment.
The facility did not adhere to NFPA 101 standards by storing soiled-linen and trash containers exceeding 32 gallons in the 1st floor corridor outside a resident's room, rather than in a 1-hour fire-rated room. This was confirmed by the Director of Maintenance.
The facility did not ensure that nurse aides completed the required 12 hours of annual inservice training. A review of five employee files showed that none of the aides had completed the necessary training, a fact confirmed by the Nursing Home Administrator.
The facility failed to ensure accurate MDS assessments for several residents, with discrepancies in medication administration and discharge status. For example, a resident's MDS inaccurately indicated anticoagulant use, while another's noted insulin administration without supporting orders. Staff interviews confirmed these inaccuracies.
The facility failed to provide scheduled showers for four residents due to staffing shortages, as revealed by resident interviews and clinical record reviews. Despite the facility's policy requiring weekly showers, residents only received bed baths, with no documentation of shower refusals. The DON confirmed the expectation for twice-weekly showers, highlighting a recurring issue with nursing services.
The facility failed to ensure monthly drug regimen reviews by a pharmacist and timely physician responses to recommendations for several residents. Recommendations for medication changes were not addressed, and some lacked physician rationale for disagreement. Interviews confirmed these deficiencies.
The facility failed to monitor a resident's fluid restriction and complete wound care treatments as ordered by physicians. A resident with congestive heart failure did not have their fluid intake monitored as required, and another resident with a full thickness wound did not receive documented wound care on several occasions. These deficiencies were confirmed by facility staff.
A facility failed to monitor a resident's weight and follow a dietitian's recommendations after a significant weight loss. The resident's weight dropped from 122.8 to 116.2 pounds, indicating a 7.9% loss over 30 days. Despite the dietitian's recommendation for weekly weights, no re-weight was obtained after March 2, and no further weights were recorded by March 14, even after a physician's order was placed.
A resident's lower dentures broke and were not repaired or replaced in a timely manner. Despite the resident's POA requesting dental services, the facility failed to refer the resident for dental care, as confirmed by staff.
The facility failed to provide appropriate PPE and door notifications for two residents on Enhanced Barrier Precautions (EBP). One resident with a Stage II sacral wound and another with a nephrostomy tube did not have EBP in place, as confirmed by the DON. The facility's policy requires PPE for high-contact care activities, which was not followed.
A resident with moderate cognitive impairment, requiring assistance with personal hygiene, was found with long and dirty fingernails. Despite morning care, the nails were not cleaned due to a scheduled doctor's appointment. This deficiency was observed and reported to the Assistant DON.
A resident with severe cognitive impairment and high fall risk fell from a window due to inadequate supervision, resulting in significant injuries. Despite being identified as a moderate elopement risk, the resident exited through an unsecured window without triggering alarms. The facility's failure to provide adequate supervision and secure the environment led to this incident.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete required performance reviews at least once every 12 months for five nurse aides. Review of personnel records for Employees E5 through E9 showed no evidence that any performance evaluations had been conducted within the required annual timeframe. During an interview, the Nursing Home Administrator confirmed that there was no documentation of performance reviews for these five nurse aides, indicating that the facility did not carry out or record the mandated periodic assessments of their job performance, as required by applicable state personnel policies and procedures.
Failure to Ensure Required Annual In‑Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides completed the required 12 hours of annual in‑service training, including education in dementia care and abuse prevention, as required by 42 CFR 483.95 and 28 Pa. Code 201.19(7). During review of personnel files for five nurse aides (Employees E5–E9), surveyors found no documentation that any of these employees had completed the mandated 12 hours of annual in‑service education. An interview with the Nursing Home Administrator confirmed that there was no evidence in the records that these nurse aides had received the required annual training hours.
Improper Labeling and Storage of Insulin Pens on Medication Carts
Penalty
Summary
Surveyors found that the facility failed to ensure proper labeling and storage of insulin pens on two of three medication carts observed. On the Second Floor Back Hall medication cart, one open Toujeo insulin pen was labeled with an open date of January 18, 2026, but had no expiration date documented, and another Toujeo insulin pen was unopened yet not stored in the refrigerator as required by the manufacturer’s directions. On the First Floor medication cart, one opened Lantus insulin pen had no open date or expiration date, and another unopened Lantus insulin pen was not refrigerated as recommended by the manufacturer. During an interview, the DON confirmed that the insulin pens on these carts were not properly identified with open and expiration dates, and that unopened insulin pens were not stored in accordance with manufacturer instructions. The deficiency was cited under 28 Pa. Code 211.12(c)(d)(1)(2)(5) related to nursing services and the requirement that drugs and biologicals be labeled and stored according to accepted professional principles.
Failure to Notify Ombudsman of Hospital Transfers and Complete Required Discharge Summary
Penalty
Summary
Surveyors determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for multiple residents. For one resident, a nursing progress note dated December 12, 2025, documented transfer to a local hospital for evaluation, but documentation provided by the Nursing Home Administrator showed that the Ombudsman was not notified, which was confirmed in an interview with an employee. Another resident’s record contained a nursing progress note dated January 17, 2026, indicating transfer to the hospital for evaluation, yet the Nursing Home Administrator’s documentation and staff interview again confirmed that the Ombudsman was not notified. A third resident was discharged to the hospital and later readmitted, but review of the clinical record did not show evidence that the Ombudsman was notified of the hospital admission, which the DON confirmed. For a closed record, a nursing progress note documented that the resident was admitted to a local hospital and discharged from the facility the same day, and review of the record and an interview with Social Services confirmed that the Ombudsman was not notified. Surveyors also found that the facility failed to complete a required discharge summary, including a recapitulation of the resident’s stay, for one closed record. For this resident, a nursing progress note documented discharge from the facility to home, and the MDS indicated the discharge was planned. However, the Nursing Home Administrator reported that the facility did not complete a discharge summary, including a recapitulation of the stay, for this resident. The Nursing Home Administrator also confirmed that the facility did not notify the Ombudsman of the hospital transfers for two of the residents reviewed. These findings were cited under 28 Pa. Code 201.14(a), Responsibility of licensee.
Inaccurate MDS Coding of Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accuracy of a resident assessment for one resident when the quarterly MDS dated February 2, 2025, indicated in section N0415 (High Risk Drug Classes) that the resident was receiving an anticoagulant. Clinical record review, including the physician’s orders and the Medication Administration Record for the assessment lookback period, showed no evidence that the resident had been ordered or administered an anticoagulant during that time. In an interview on February 27, 2025, at 12:10 p.m., licensed staff member E3 confirmed that the MDS assessment had been coded inaccurately, resulting in an assessment that did not accurately reflect the resident’s actual medication regimen. This deficiency was cited under 42 CFR 483.20 related to the accuracy of assessments and 28 Pa. Code 211.5(f) regarding clinical records, and had been previously cited on multiple prior survey dates.
Failure to Involve Resident in Interdisciplinary Care Plan Process
Penalty
Summary
The facility failed to invite a resident and/or the resident’s representative to participate in the care plan process as required. Resident 37’s clinical record showed that the resident was admitted to the facility on the documented admission date, and review of the record revealed no evidence that the resident or the resident’s representative had been invited to attend or participate in interdisciplinary care plan meetings. During an interview on February 24, 2026, at 11:10 a.m., Resident 37 stated that they had not been invited to participate in an interdisciplinary care plan meeting. An interview with the Nursing Home Administrator on February 27, 2026, at 12:00 p.m. confirmed that there was no documentation or evidence that the resident or the resident’s representative had been invited to an interdisciplinary care plan meeting, resulting in noncompliance with resident rights and nursing services requirements. All findings were based on review of the clinical record and interviews with the resident and the Nursing Home Administrator, and no additional medical history or clinical condition details for the resident were documented in the report.
Failure to Follow Medication and NPO Orders for Two Residents
Penalty
Summary
The facility failed to provide treatment and care in accordance with standards of care for two residents. One resident had a diagnosis that included secondary malignant neoplasm of the lung and was ordered to receive 4 mg of decadron the day before, the day of, and the day after a scheduled cancer infusion. The Medication Administration Record showed that decadron was administered on February 24, 2026, in preparation for an infusion appointment at a cancer center on February 25, 2026. However, the resident did not attend the infusion appointment because transportation had not been arranged, and the appointment had to be rescheduled. A subsequent progress note documented that the CRNP ordered discontinuation of the three days of decadron since the infusion was not given. Another resident had an order to remain NPO after midnight prior to a scheduled cataract surgery. Nursing had sent a Diet Order and Communication slip to the kitchen indicating that this resident was not to receive a breakfast tray on the morning of the scheduled surgery. Despite this written communication and the active NPO order, the resident received a breakfast tray from the kitchen and ate breakfast, resulting in the cancellation of the cataract surgery appointment. The DON confirmed that the resident received a breakfast tray while the NPO order was in place.
Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to follow physician orders for a resident with multiple chronic pain diagnoses, including osteoarthritis of the left knee, left hip pain, arthritis in the left hip, and lower back pain. The physician had ordered a Fentanyl transdermal patch to be applied every 72 hours for pain management. Review of the Medication Administration Records (MAR) showed no documentation that the patch was removed and reapplied as ordered between December 1 and December 6, 2025. The resident confirmed that the pain patch was not changed during this period, experienced pain, and reported it to nursing staff, but the patch was still not changed. The Nursing Home Administrator acknowledged that the medication was not administered properly.
Failure to Assist Residents Out of Bed for Scheduled Activities
Penalty
Summary
The facility failed to ensure that residents were assisted out of bed in a timely manner to attend scheduled Sunday religious services. Interviews with the Activities Director and Activities Assistant revealed that this issue occurs every weekend, with 1-2 residents unable to attend services each week because nursing staff do not provide assistance out of bed in time. Both staff members reported that they did not inform the Nursing Home Administrator about the recurring problem. Additionally, a resident confirmed missing a recent Sunday service due to not being assisted out of bed before the scheduled time, despite staff being aware of her need to be up before 9:30 a.m. These findings were confirmed by the Nursing Home Administrator.
Failure to Implement Contact Precautions for Scabies Diagnosis
Penalty
Summary
The facility failed to implement contact precautions for a resident diagnosed with scabies. Review of the resident's clinical record showed a diagnosis of scabies with a start date of October 28, 2025. The facility's policy required affected residents to remain on contact precautions until twenty-four hours after treatment. However, there were no physician orders for contact precautions in the resident's record, and observations of the resident's room revealed no signage indicating that contact precautions were in place. The resident had an order for Permethrin 5% cream, but treatment was to be held until after a dermatology appointment. During interviews, the Assistant Director of Nursing (ADON) stated she was not informed of the resident's recent scabies diagnosis and confirmed that contact precautions should have been implemented upon diagnosis. The ADON also noted that previous dermatology appointments did not indicate scabies. The resident was unavailable for interview due to cognitive impairment. The lack of communication and failure to follow facility policy led to the deficiency in infection prevention and control.
Failure to Provide Scheduled Showers to Multiple Residents
Penalty
Summary
The facility failed to provide scheduled showers to six out of eight residents reviewed, as evidenced by clinical record reviews, staff and family interviews, and direct observations. Multiple residents, including those with cognitive impairments and those requiring moderate to total assistance for activities of daily living, did not receive showers according to their documented preferences and schedules. Instead, these residents were given bed baths on several occasions, with no documentation that showers were offered on the scheduled days. For example, one resident with cognitive impairment and moderate care needs was scheduled for showers twice weekly but only received bed baths on select dates, with no evidence of being offered showers on other scheduled days. Another resident with diabetes mellitus received only a bed bath and was unaware of her shower schedule, expressing a preference for showers over bed baths. Observations noted that this resident appeared unkempt, with greasy hair and dirty fingers. Additional residents, both cognitively impaired and intact, also missed scheduled showers, with records showing only bed baths provided and no documentation of showers being offered. Interviews with these residents revealed dissatisfaction with the lack of showers, with one resident reporting feeling unclean and experiencing a rash, and another stating that showers were missed when there was insufficient staff. The DON and Nursing Home Administrator confirmed the absence of documentation for showers on the specified dates. These findings indicate a failure to provide care and assistance with activities of daily living, specifically bathing, as required by facility policy and resident preference.
Failure to Provide Sufficient Nursing Staff for Resident Showers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the scheduled bathing and showering needs of residents, as required by policy. Multiple residents, including those with cognitive impairments and those dependent on staff for daily care, did not receive showers according to their preferred or scheduled times. Bathing records showed that several residents received only one or two showers over a period of more than a month, despite not refusing care. Observations and interviews confirmed that residents were left unkempt, with dirty hair, unclean bodies, and in some cases, visible rashes. Residents expressed a preference for showers over bed baths and reported being told that staff shortages were the reason for missed showers. Staff interviews corroborated the lack of adequate staffing, with nurse aides and an LPN stating that they were unable to complete all required showers and daily care tasks due to insufficient personnel. Staff reported having to rotate which residents received showers and being unable to provide quality care, including turning and repositioning. The Nursing Home Administrator and Director of Nursing acknowledged the staffing challenges. These findings were based on a review of facility policies, clinical records, and direct interviews and observations.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records for multiple residents were complete and accurately documented, as required by accepted professional standards. Specifically, for six out of eight residents reviewed, there were missing or incomplete entries in the shower records for various dates. In several instances, documentation was left blank or marked as 'NA,' which was confirmed by the Director of Nursing to be unacceptable. These documentation lapses were identified through clinical record reviews and staff interviews. The residents affected included individuals with cognitive impairments and those requiring moderate to total assistance with personal care, such as showering. The deficiencies were noted across both cognitively impaired and intact residents, with some having significant medical conditions like diabetes mellitus. The lack of proper documentation was observed over multiple months and for multiple residents, indicating a pattern of incomplete record-keeping for essential care activities.
Failure to Implement Surveillance System for Infectious Skin Conditions
Penalty
Summary
The facility failed to implement a system of surveillance to identify, prevent, monitor, and report potential infectious skin conditions. Observations revealed that one resident had a persistent rash on her upper arms, chest, and back, which she described as feeling like bugs crawling on her. Another resident was observed with a rash over his arms, chest, and back, and had recently received permethrin cream for treatment after other interventions were unsuccessful; he reported relief from itching following this treatment. Clinical records confirmed the administration of permethrin cream, but there was no testing for scabies as the presentation was considered atypical, and a dermatology follow-up was pending. Interviews with the infection prevention nurse and the DON confirmed that there was no system in place to track and trend skin conditions, with each believing the other was responsible for this task. The nurse practitioner also indicated that tracking and trending of skin conditions was the responsibility of the infection prevention nurse.
Failure to Investigate Alleged Abuse and Neglect Incidents
Penalty
Summary
The facility failed to conduct thorough investigations into incidents involving two residents, as required by its abuse policy and state regulations. For one resident with Alzheimer's Disease and dementia, a grievance was filed by her daughter after a male resident was found in her bed and was only removed after the roommate called for staff assistance for several minutes. There was no documentation of the incident in the resident's medical records, nor any evidence that an investigation was completed to determine if neglect or abuse had occurred. In a separate incident, another resident who was cognitively intact and dependent on staff for care sustained a skin tear. Although the Director of Nursing heard a noise and checked on the resident, there was no documented investigation to rule out neglect or abuse. Interviews with facility leadership confirmed that written statements were not obtained from staff or residents involved, and no formal investigation was conducted for either incident.
Failure to Complete RN Assessment After Resident Incident
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) completed an assessment after an incident in which a male resident was found in the bed of a female resident. According to the Pennsylvania Nursing Practice Act and the facility's own risk management policy, an RN assessment should be documented in the clinical record following such incidents. However, review of the clinical record for the affected resident revealed no evidence that an RN assessment was performed after the event. The resident involved was cognitively impaired, with diagnoses including Alzheimer's Disease and dementia, and required moderate assistance from staff. The incident was brought to attention through a grievance filed by the resident's daughter, who reported that the male resident was only removed after the roommate called for staff for several minutes. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that no RN assessment was completed at the time of the incident.
Failure to Maintain Common Wall Doors
Penalty
Summary
The facility failed to maintain the common wall doors to positively latch on two of two floors within the component. During an observation conducted on March 31, 2025, between 12:00 PM and 2:00 PM, it was noted that the common wall doors did not positively latch at specific locations. At 12:00 PM, the issue was observed on the upper level at the common wall between Components 01 and 02. Similarly, at 2:00 PM, the same issue was noted on the lower level at the common wall between Components 01 and 02. An interview with the Director of Maintenance at 2:20 PM on the same day confirmed the failure of the common wall doors to positively latch.
Plan Of Correction
1. The common wall doors between Components 01 and 02 have been adjusted to positively latch. 2. The corrective action was completed on 4/1/2025. 3. The Maintenance Director or Designee will conduct audits of the common wall doors between Components 01 and 02 quarterly for 1 year. 4. Findings of Audits will be submitted to QAPI for review.
Stair Tower Door Gap Deficiency
Penalty
Summary
The facility failed to maintain stair tower doors within the allowed gap margins on one of two floors. This deficiency was identified through observation and interview, indicating a lapse in maintaining the required standards for stairways and smokeproof enclosures as exits, as per NFPA 101 standards.
Plan Of Correction
1. The 1st floor stairtower doors by Resident Room 215 have been adjusted to have gaps less than 3/16 inch. 2. The corrective action was completed on 4/10/2025. 3. The Maintenance Director or Designee will conduct audits of all facility stairtower doors to have gaps less than 3/16-inch quarterly for 1 year. 4. Findings of Audits will be submitted to QAPI for review.
Deficiencies in Corridor Door Maintenance
Penalty
Summary
The facility was found to have deficiencies related to the maintenance of corridor doors, which are crucial for fire safety and smoke containment. On March 31, 2025, an observation revealed that the stairtower doors on the 1st floor, near Resident Room 215, had gaps greater than the allowed 3/16 inch. This was confirmed by an interview with the Director of Maintenance, indicating that the doors exceeded the permissible gap margins, thus failing to meet the National Fire Protection Association (NFPA) 101 standards for corridor doors. Additionally, further observations on the same day revealed that the corridor doors to Resident Rooms 215 and 205 failed to close and latch properly. These findings were also confirmed through interviews with the Director of Maintenance. The inability of these doors to close and latch compromises their effectiveness in resisting the passage of smoke, which is a critical safety requirement, especially in fully sprinklered smoke compartments. These deficiencies highlight a failure in maintaining the required safety standards for corridor doors within the facility.
Plan Of Correction
1. The corridor doors to Resident Rooms 205 and 215 have been adjusted to close and latch. 2. The corrective action was completed on 4/1/2025. 3. The Maintenance Director or Designee will conduct a facility wide audit of all facility corridor doors for closure and latch then random door checks monthly. 4. Findings of Audits will be submitted to QAPI for review.
Improper Storage of Soiled-Linen and Trash Containers
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the storage of soiled-linen and trash containers. During an observation on March 31, 2025, at 12:50 PM, it was noted that soiled-linen and trash containers exceeding 32 gallons were stored in the 1st floor corridor outside Resident Room 221. These containers were not placed in a 1-hour fire-rated room as required. An interview with the Director of Maintenance at the same time confirmed that the containers were not stored in a rated assembly, indicating a lapse in adherence to safety protocols for hazardous areas.
Plan Of Correction
1. The soiled linen and trash containers were removed from outside resident room 221. 2. The corrective action was completed on 4/1/2025. 3. The Maintenance Director or Designee will conduct audits of the 1st and 2nd floor corridors for soiled linen and trash containers daily until compliance is achieved, then weekly on all 3 shifts x 4 and then randomly for 2 months. 4. Findings of Audits will be submitted to QAPI for review.
Failure to Complete Required Annual Inservice Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides completed the required 12 hours of annual inservice training. A review of five nurse aide employee files revealed that none of the aides had completed the necessary training. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the five nurse aides did not fulfill the annual training requirement.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for five of the 24 residents reviewed. Specifically, the Minimum Data Set (MDS) assessments for several residents contained inaccuracies regarding medication administration and discharge status. For instance, Resident 1's quarterly MDS inaccurately indicated that the resident was receiving anticoagulant medication, despite the absence of such an order or administration in the Medication Administration Record (MAR). Similarly, Resident 39's MDS incorrectly noted insulin administration, which was not supported by physician orders or the MAR. Further discrepancies were noted with Resident 45 and Resident 58, whose MDS assessments inaccurately reflected the administration of anticoagulants, contrary to their physician orders and MAR records. Additionally, Resident 78's discharge MDS inaccurately documented the discharge destination as a short-term general hospital, while records indicated the resident was discharged home. These inaccuracies were confirmed through staff interviews, highlighting a failure in the facility's assessment processes.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for residents unable to carry out activities of daily living. This deficiency was identified for four residents who were reviewed during the survey. The facility's policy, revised in August 2018, mandates that residents should receive showers or baths at least weekly, considering their preferences. However, interviews with residents revealed that they did not receive showers as scheduled due to staffing shortages. Specifically, Residents 2, 6, 14, and 25 reported not receiving showers, and there was no documentation indicating that they refused showers. Clinical record reviews showed that Residents 2, 6, and 14, who had moderate cognitive impairment and required assistance for bathing, did not receive showers from February 26 to March 13, 2025, but only received bed baths. Similarly, Resident 25, who was cognitively intact and required partial assistance, also did not receive a shower during the same period. The Director of Nursing confirmed that residents are supposed to receive showers twice a week and should be offered a bed bath if a shower is refused. The facility was previously cited for similar deficiencies, indicating a recurring issue with maintaining adequate nursing services and clinical records.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review for each resident and that the physician addressed all pharmacy recommendations in a timely manner. This deficiency was identified for four out of five residents reviewed. For Resident 5, the pharmacist made recommendations on multiple occasions, but the physician did not respond to the recommendations made in March and September 2024. Additionally, a recommendation made in June 2024 lacked a rationale for the physician's disagreement, and a recommendation from February 2025 was not reviewed until March 2025. Similarly, for Resident 28, the pharmacist made several recommendations throughout 2024, but there was no evidence of the physician's response. Resident 34's record showed that recommendations made in March, September, and October 2024 were not reviewed by the physician, and no changes were made. For Resident 59, recommendations made in March and September 2024 were also not addressed by the physician. Interviews with the Nursing Home Administrator and Director of Nursing confirmed these findings.
Failure to Monitor Fluid Restriction and Complete Wound Care
Penalty
Summary
The facility failed to monitor a resident's fluid restriction and complete treatments according to physician orders for two residents. Resident 4, diagnosed with congestive heart failure, had a physician's order for a daily fluid restriction of 1500 ml. The order specified the distribution of fluids between the Dietary and Nursing departments. However, a review of Resident 4's clinical records from January to March 2025 revealed no evidence that the nursing staff was monitoring the resident's total daily fluid intake in conjunction with the Dietary department. This was confirmed during an interview with the Nursing Home Administrator and Director of Nursing. Resident 45 had a full thickness wound with 100% eschar on the right heel and foot. Physician's orders required daily cleansing and dressing of the wound. However, the February and March 2025 Medication Administration Records (MAR) showed that the treatment was not documented as completed on multiple occasions. This lack of documentation was confirmed by the Director of Nursing during an interview. These deficiencies were previously cited in February 2024 under the Quality of Care and Nursing Services regulations.
Failure to Monitor Resident's Weight and Follow Dietitian's Recommendations
Penalty
Summary
The facility failed to ensure routine nutrition monitoring for a resident, identified as Resident 66, by not obtaining re-weights and not following the recommendations made by a registered dietitian. According to the facility's policy titled 'Weight Assessment and Intervention,' any weight change of 5 pounds or more should be retaken for confirmation, and significant unplanned weight loss should be reported to the physician and dietitian. Resident 66 experienced a weight loss from 122.8 pounds to 116.2 pounds within a short period, which was noted by the dietitian as a 7.9% weight loss over 30 days. Despite this significant weight loss, there was no evidence of a re-weight being obtained after March 2, 2025, as required by the facility's policy. The clinical record review also revealed that the dietitian recommended weekly weights for three weeks, but there was no order for these weekly weights until March 10, 2025. Even after the order was placed, no further weights were obtained by March 14, 2025. An interview with the Director of Nursing and the Nursing Home Administrator confirmed that no re-weight was obtained after the significant weight loss was identified, and no further weights were taken in accordance with the physician's order. This failure to monitor the resident's weight and follow the dietitian's recommendations constitutes a deficiency in the facility's nutritional monitoring practices.
Failure to Timely Provide Dental Services
Penalty
Summary
The facility failed to timely provide dental services for a resident, identified as Resident 19, whose lower dentures broke after falling on the floor on January 6, 2025. The dentures were placed at the nursing station, but no immediate action was taken to repair or replace them. On March 13, 2025, the resident's power of attorney requested that the process for obtaining new dentures be initiated, and the resident was added to the dentist list. However, a review of the clinical record showed no evidence that the resident was referred for dental services. This was confirmed in an interview with Employee E4 on March 14, 2025, who acknowledged that the resident had not been referred for dental services.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was available and proper door notifications were in place for residents on Enhanced Barrier Precautions (EBP). This deficiency was identified for two residents during the survey. Resident 4, who had a Stage II sacral wound, did not have any evidence of EBP being utilized in their room, doorway, or hallway area. The Director of Nursing confirmed that no EBPs were being used for the treatment of Resident 4's wound. Similarly, Resident 63, who had a nephrostomy tube, also lacked evidence of EBP in their room throughout the survey. The Director of Nursing confirmed that enhanced barrier precautions were not in place for Resident 63. The facility's policy on EBPs requires the use of gown and gloves for high-contact resident care activities and mandates that PPE be available at the resident's room, which was not adhered to in these cases.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident with moderate cognitive impairment who required partial/moderate assistance with personal hygiene. During an observation, the resident was found with long and dirty fingernails, with a dried brown stain or substance underneath. Despite morning care being provided, the non-licensed staff member did not clean the resident's fingernails because the resident had a doctor's appointment. This deficiency was noted during an interview with the staff member and was later communicated to the Assistant Director of Nursing.
Resident Falls from Window Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision of a resident, leading to a fall from a window and subsequent hospitalization. The resident, who had a history of left side hemiplegia, vascular dementia, and severe cognitive impairment, was identified as a high fall risk and moderate elopement risk. Despite these risks, the resident was able to exit the building through a window, resulting in significant injuries including facial fractures, rib fractures, a pneumothorax, and a subarachnoid hemorrhage. The resident's care plan included interventions for fall risk and elopement, such as assisting with transfers and ambulation, providing orientation and diversional activities, and checking the function of a wanderguard. However, on the night of the incident, the resident was last seen in a wheelchair near their room and was later found outside the building without the wheelchair. The wheelchair was discovered near an open window in the activity room, indicating the resident had exited through the window without triggering any alarms. Interviews and observations revealed that no staff were present in the activity room at the time of the incident, and the window had stop brackets that were not effective in preventing the resident's exit. The facility's failure to provide adequate supervision and secure the environment contributed to the resident's fall and subsequent injuries, highlighting deficiencies in management and nursing services as previously cited in past surveys.
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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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