Gardens For Memory Care At Easton, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Easton, Pennsylvania.
- Location
- 500 Washington Street, Easton, Pennsylvania 18042
- CMS Provider Number
- 395708
- Inspections on file
- 17
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Gardens For Memory Care At Easton, The during CMS and state inspections, most recent first.
The facility failed to maintain a safe, clean, and comfortable environment on two nursing units. Observations revealed loose assist bars on toilets, soiled and damaged furnishings, and inadequate housekeeping in several rooms, including rooms 204, 307, 309, 311, 312, 313, and 314, as well as common areas like the dining room.
The facility did not provide devices for heating food in the service pantries of two nursing units, as observed on two separate days. A RN stated that all microwave ovens were removed from the pantries because resident families were frequently asking staff to reheat food.
The facility did not meet the required nurse aide (NA) to resident ratios on several occasions, failing to maintain the minimum staffing levels during day, evening, and night shifts over a 21-day period. This was confirmed by the facility's administrator after a review of nursing schedules.
The facility did not meet the required 3.2 hours of direct nursing care per resident on four specific days, with care hours ranging from 2.86 to 3.11. The administrator confirmed the shortfall during an interview.
A facility failed to implement safety interventions for a resident with behavioral symptoms, leading to an incident where one resident entered another's room, triggering a physical response. The resident with traumatic brain injury and dementia was supposed to have a stop sign on his door to prevent such incidents, but it was not in place, as confirmed by the Administrator. This deficiency was previously cited under relevant regulations.
A facility failed to implement safety measures for a resident at risk for falls and did not prevent another resident at risk for elopement from leaving a secured area. One resident was observed without prescribed fall mats, and another resident, identified as a high risk for elopement, was found outside the secured unit unsupervised due to a staff oversight.
Environmental Deficiencies in Resident Rooms and Common Areas
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment on two nursing units, specifically the second and third floors. Observations revealed several environmental issues, including loose and wobbly assist bars on toilets in rooms 204, 307, and 309, which could pose a safety risk to residents. Additionally, the towel racks in room 307 were loose, and there was a dried orange substance on the floor in front of the closets for beds three and four in room 309. The bathroom doorway in room 311 was soiled with a dried brown stain, and the heater was damaged. The window curtain in room 312 was soiled, and the fall mat had dust and several dried, gray spots on it, while the pedal to control bed height was covered with a layer of dust. Further observations included a soiled floor with a brown substance and a damaged heater with peeling paint by the heater in room 313. There was a cracked tile and peeling wallpaper near the window in the dining room, and the privacy curtain in room 314 (bed one) was soiled with brown stains. These findings indicate a failure to maintain a sanitary, orderly, and comfortable interior, as required by the regulations, and highlight the need for improved housekeeping and maintenance services to ensure a safe and homelike environment for residents.
Plan Of Correction
1. The facility has repaired the loose and wobbly assist bars in rooms 204, 307, and 309. The towel racks in room 307 were secured, and the scuffed and damaged table in the dining room across from room 215 was replaced. The dried orange substance in room 309, the brown stain in room 311, and the brown substance on the floor in room 313 were cleaned. Heater damages in rooms 311 and 313 were repaired. The soiled window curtain in room 312 and the privacy curtain in room 314 were removed and replaced with clean curtains. Additionally, the fall mat and bed pedal in room 312 were thoroughly cleaned and sanitized. The cracked tile and peeling wallpaper in the dining room were repaired, and the affected area was repainted. Peeling paint by the heater in room 313 will be repaired. 2. An environmental audit of all resident rooms and common areas was conducted to identify any similar environmental concerns. Any issues identified were immediately addressed. 3. All Maintenance Department staff will be reeducated on Weekly Environmental Safety Rounds. All Housekeeping staff will be reeducated on daily cleaning protocols. 4. Environmental audits will be completed weekly. Findings from audits will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings, and QAPI will determine further action planning and discontinuation.
Absence of Food Heating Devices in Nursing Unit Pantries
Penalty
Summary
The facility failed to provide a device for heating food in the service pantries of two nursing units, specifically on the second and third floors. This deficiency was identified through observations conducted on April 29 and April 30, 2025, which revealed the absence of any devices to reheat food in the pantries of these units. During an interview on April 29, 2025, a Registered Nurse (RN) explained that the facility had removed all microwave ovens from the nursing unit pantries. The reason given for this action was that resident families were frequently requesting staff to reheat food, leading to the decision to remove the devices.
Plan Of Correction
1. Microwave ovens for heating food have been installed in both nursing unit pantries. 2. All residents residing were reviewed to ensure that the lack of heating devices in the pantries did not negatively impact their nutritional services or access to hot meals. No adverse outcomes were identified. 3. All Licensed nursing staff will be re-educated on the purpose of the pantry appliances and the proper use of the machines. 4. Audits to confirm that both pantries have microwave ovens for use will be completed weekly. Findings from audits will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings, and QAPI will determine further action planning and discontinuation.
Failure to Meet Nurse Aide to Resident Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios on multiple occasions over a period of 21 days. Specifically, the facility did not maintain the minimum ratio of one NA per ten residents during the day shift on nine separate days, one NA per eleven residents during the evening shift on three days, and one NA per fifteen residents during the night shift on five days. These deficiencies were identified through a review of nursing schedules for the periods of January 1 through 7, 2025, March 9 through 16, 2025, and April 24 through 30, 2025. The facility's administrator confirmed the failure to meet the required staffing ratios during an interview conducted on April 30, 2025.
Plan Of Correction
1. The facility has reviewed and adjusted staffing schedules to ensure compliance with minimum NA-to-resident ratios for all shifts. 2. A comprehensive review of the resident census and care needs was conducted to verify that current NA staffing levels meet or exceed regulatory requirements. A proactive system was developed to forecast NA staffing needs based on anticipated resident census and staff availability trends. 3. All nursing administrative staff will receive training on regulatory NA staffing requirements and the importance of timely shift coverage. 4. Daily audits of NA to resident ratios will be conducted weekly. Findings from audits will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings, and QAPI will determine further action planning and discontinuation.
Deficiency in Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. This deficiency was identified during a review of nursing schedules over a 21-day period, specifically on four days: March 15, April 25, April 26, and April 27, 2025. On these days, the facility provided 3.11, 3.05, 3.10, and 2.86 hours of care per resident, respectively, which were below the mandated minimum. The facility administrator confirmed the shortfall in nursing care hours during an interview conducted on April 30, 2025.
Plan Of Correction
1. The facility has reviewed and adjusted staffing schedules to ensure compliance with a minimum of 3.2 hours of direct care for each resident daily. 2. A comprehensive review of the resident census and care needs was conducted to verify that current nursing staffing levels meet or exceed regulatory requirements. A proactive system was developed to forecast nursing staffing needs based on anticipated resident census and staff availability trends. 3. All nursing administrative staff received training on regulatory minimum 3.2 hours of direct care for each resident daily. 4. Daily audits of a minimum of 3.2 hours of direct care for each resident daily will be conducted weekly. Findings from audits will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings, and QAPI will determine further action planning and discontinuation.
Failure to Implement Safety Interventions for Residents
Penalty
Summary
The facility failed to ensure that safety interventions were in place for a resident at risk for behavioral symptoms. Resident 1, who had diagnoses including traumatic brain injury and dementia with behavioral disturbance, was supposed to have a stop sign on his door to prevent other residents from entering his room. This intervention was part of his care plan to prevent anxiety and ineffective coping when his belongings were touched. However, on November 24, 2024, Resident 1 exhibited physical behaviors towards another resident, Resident 2, after the latter entered his room. The stop sign, which was meant to deter wandering residents and prevent potential triggers for Resident 1's behaviors, was not in place at the time of the incident. Resident 2, who had diagnoses including dementia with mood and psychotic disturbance and anxiety, was noted to wander throughout the nursing unit and exhibited aggressive behaviors. On November 23, 2024, staff observed Resident 2 wandering into other residents' rooms. The lack of the stop sign on Resident 1's door, as confirmed by the Administrator on November 27, 2024, contributed to the incident where Resident 2 entered Resident 1's room, leading to Resident 1's physical response. This deficiency was previously cited on June 13, 2024, under CFR 483.25(d)(1)(2) and 28 Pa. Code 211.12(d)(1)(5).
Failure to Implement Safety Measures for Fall and Elopement Risks
Penalty
Summary
The facility failed to implement assessed safety measures for a resident at risk for falls and did not prevent another resident at risk for elopement from leaving a secured area without staff knowledge. Resident 20, who had Alzheimer's disease and a history of falls, was observed without the prescribed bilateral fall mats next to her bed, despite a physician's order and care plan intervention indicating their necessity. This oversight was noted during observations conducted over a three-hour period. Additionally, Resident 75, diagnosed with Alzheimer's disease and dementia with severe psychotic disturbance, was identified as a high risk for elopement. Despite interventions in place to distract her from wandering, the resident was found outside the secured nursing unit unsupervised. The incident occurred when a nurse aide left the unit without ensuring the door was locked, allowing the resident to exit. Witness statements confirmed the resident's exit-seeking behavior and the lack of staff awareness of her departure.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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