Haven Convalescent Home, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in New Castle, Pennsylvania.
- Location
- 725 Paul Street, New Castle, Pennsylvania 16101
- CMS Provider Number
- 396106
- Inspections on file
- 19
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Haven Convalescent Home, Inc during CMS and state inspections, most recent first.
The facility failed to maintain documentation for the required 36-month exercise of its emergency generators, as observed during a survey. The administrator confirmed the absence of this documentation, indicating non-compliance with NFPA standards for emergency power systems.
The facility did not conduct the required semi-annual kitchen suppression testing and exhaust hood cleaning. Documentation revealed that the last testing and cleaning were conducted in February 2024, and the administrator confirmed these were not performed within the required timeframe.
The facility did not meet the required maintenance and testing standards for its sprinkler system, as observed in the basement laundry room where dust accumulation on sprinkler heads was found. This issue was confirmed by the administrator.
A facility failed to follow infection control practices for enhanced barrier precautions (EBP) during a wound dressing change for a resident with a sacral wound and foley catheter. Staff did not wear appropriate PPE, such as gowns, and there was no signage or PPE available outside the resident's room. The DON confirmed that EBP was not maintained for residents with medical devices, despite the need for gloves and gowns during care.
The facility failed to meet the required minimum nurse aide (NA) to resident ratio during the overnight shift for 18 out of 21 days reviewed. The regulation mandates a minimum of one NA per 15 residents overnight, but the facility did not comply with this requirement on multiple occasions. The Nursing Home Administrator confirmed the accuracy of the staffing information and acknowledged the facility's failure to meet the staffing requirements on the specified dates.
The facility did not meet the required LPN staffing levels, failing to maintain the minimum ratio of one LPN per 25 residents during the day shift on one occasion and one LPN per 40 residents on the overnight shift on eight occasions. The facility census ranged from 88 to 90 residents, but the number of LPNs on duty was insufficient according to the regulations. The Nursing Home Administrator confirmed these deficiencies.
The facility did not meet the required minimum of 3.2 hours of direct resident care per resident in a 24-hour period, providing only 3.16 hours on one occasion. The Nursing Home Administrator confirmed the staffing shortfall.
Emergency Generator Maintenance Documentation Deficiency
Penalty
Summary
The facility failed to maintain proper documentation for the maintenance of its emergency generators, specifically regarding the requirement to exercise the generators once every 36 months for four continuous hours. This deficiency was identified during an observation on December 19, 2024, at 9:35 a.m., when it was noted that the facility lacked the necessary documentation to confirm compliance with this requirement. During an interview conducted at the same time, the facility's administrator confirmed that the documentation for the emergency generator exercise was unavailable for review. This lack of documentation indicates a failure to adhere to the maintenance and testing protocols as outlined by NFPA standards, which are critical for ensuring the reliability of emergency power systems in the facility.
Plan Of Correction
The Haven will test the 2 facility generators for at least 4 consecutive hours. The 4 hour test will occur at least once every three years. The Haven did lose power on 3/25/2023 for 8 hours and 15 minutes. The generator did run for the entire time and functioned accordingly. The Administrator will monitor testing of the facility.
Failure to Conduct Required Kitchen Suppression Testing and Hood Cleaning
Penalty
Summary
The facility failed to ensure that the kitchen suppression testing and kitchen exhaust hood cleanings were conducted at the required semi-annual intervals. During a document review on December 19, 2024, it was revealed that the last documented kitchen suppression testing occurred on February 2, 2024, indicating a lapse in the required testing schedule. An interview with the administrator confirmed that the semi-annual kitchen suppression testing had not been conducted within the required timeframe. Additionally, the document review showed that the last documented kitchen exhaust hood cleaning was on February 20, 2024, further confirming that the semi-annual cleaning had not been performed as required. The administrator also confirmed this lapse during the interview.
Plan Of Correction
Kitchen suppression system testing/maintenance was conducted on 12/19/2024. Kitchen exhaust hood cleaning was conducted on 1/06/2025. Kitchen suppression system testing/maintenance and kitchen hood cleaning will be performed at least semi-annually. Both services have been scheduled to be done at least every 6 months from the latest completion date.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to meet the maintenance and testing requirements for its sprinkler system on one of two building levels. During an observation on December 19, 2024, at 10:45 a.m., it was noted that the sprinkler heads in the basement laundry room had an accumulation of dust. This accumulation can potentially delay the activation of the sprinklers during an emergency. The deficiency was confirmed through an interview with the administrator at the same time.
Plan Of Correction
Sprinkler heads in the laundry room were cleaned of dust by maintenance. Maintenance will monitor the laundry room sprinkler heads for accumulation of dust at least once a week and clean them as needed. Laundry personnel informed to notify Administration if they notice an accumulation of dust on the sprinkler heads in the laundry room. Administration will notify maintenance to clean the sprinkler heads. Administrator to monitor laundry room sprinkler heads weekly x 4 weeks and then at least monthly to ensure the sprinkler heads are free of dust. Monitoring will occur until deemed in compliance by the facility Quality Assurance and Performance Improvement Committee.
Inadequate Infection Control Practices for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to acceptable infection control practices concerning enhanced barrier precautions (EBP) during the care of a resident with a sacral wound and a foley catheter. Specifically, during a wound dressing change for Resident R78, both the Registered Nurse (RN) and the Nursing Assistant (NA) did not wear the appropriate personal protective equipment (PPE), such as gowns, which is required under EBP. This lapse was confirmed by RN Employee E1 during an interview, acknowledging that a gown should have been worn during the procedure. Additionally, the facility did not have any signage or PPE available outside Resident R78's room to alert or equip staff and visitors regarding EBP. The Director of Nursing (DON) confirmed that the facility had several residents with medical devices such as foley catheters, feeding tubes, colostomies, wounds, and dialysis catheters, yet EBP was not maintained for these residents. The DON acknowledged that staff should have been wearing gloves and gowns when providing care to these residents, indicating a systemic issue in the facility's infection control practices.
Plan Of Correction
Policy on Enhanced Barrier Precautions was added to the Facility Infection Control Policies. All residents of the facility who require Enhanced Barrier Precautions were ordered enhanced barrier precautions by their physician. Appropriate signage was placed on the doors of the residents who were ordered enhanced barrier precautions and appropriate PPE was made available. A letter was mailed out to each resident's responsible person concerning enhanced barrier precautions. Nursing was in-serviced by the Director of Nursing on 12/19/2024 on Enhanced Barrier Precautions. Infection preventionist or nurse designee will monitor residents on Enhanced Barrier to ensure that the appropriate signage and PPE is provided and that staff are donning, doffing and utilizing the appropriate PPE as needed when caring for these residents. Monitoring will occur at least once a week on all 3 shifts weekly for 4 weeks and then at least monthly until deemed in compliance by facility QAPI Committee.
Overnight Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) to resident ratio during the overnight shift for 18 out of 21 days reviewed. The regulation mandates a minimum of one NA per 15 residents overnight, but the facility did not comply with this requirement on multiple occasions. The review of nursing staffing documents revealed that the number of NAs working was consistently below the required number based on the facility's census. For instance, on several dates, the facility had a census of 89 to 90 residents, but the number of NAs working ranged from 4.75 to 5.75, whereas the required number was between 5.80 and 6.00. The Nursing Home Administrator confirmed the accuracy of the staffing information and acknowledged the facility's failure to meet the staffing requirements on the specified dates. This deficiency was identified through a review of staffing documents and an interview with the administrator, highlighting a consistent shortfall in staffing levels during the overnight shift over the reviewed periods.
Plan Of Correction
Facility Staffing Coordinator was reeducated on current CNA staffing ratios according to current census and shifts. Facility will attempt to utilize facility staff and temporary staffing agencies as needed. Facility weekly Schedule will be made in accordance with current Pennsylvania DOH Staffing guidelines and facility census. Nursing Supervisors to be in-serviced on staffing guidelines by 1/8/2025. For the shifts on the dates indicated, all residents in the facility received the care that they required, and the facility received no complaints from residents, their responsible person(s), or employees. Schedule and census will be monitored daily per shift by RN Nursing Supervisor for call offs and changes in census. Adjustments will be made as needed by Director of Nursing, RN Nursing Supervisor, or Staffing Coordinator. Facility will utilize facility staff and or temporary Staffing Agencies to fill in shifts as needed according to type of nursing service personnel that is needed. Assistant Administrator or designee will monitor schedules at least weekly x 4 weeks and then every 2 weeks until deemed in compliance by facility QAPI Committee.
LPN Staffing Deficiencies in Facility
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) as mandated by regulations effective July 1, 2023. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift on one occasion and failed to meet the minimum ratio of one LPN per 40 residents on the overnight shift on eight occasions. The review of staffing documents revealed that on December 7, 2024, with a census of 89 residents, only 3.0 LPNs were on duty when 3.56 were required. Additionally, during the overnight shifts on multiple dates, the facility census ranged from 88 to 90 residents, but only 2.0 LPNs were on duty when between 2.20 and 2.25 were required. The Nursing Home Administrator confirmed these staffing deficiencies during an interview.
Plan Of Correction
Facility Staffing Coordinator was reeducated on current LPN staffing ratios according to current census and shifts. Facility will attempt to utilize facility staff and temporary staffing agencies as needed. Facility weekly Schedule will be made in accordance with current Pennsylvania DOH Staffing guidelines and facility census. Nursing Supervisors to be in-serviced on staffing guidelines by 1/8/2025. For the shifts on the dates indicated, all residents in the facility received the care that they required, and the facility received no complaints from residents, their responsible person(s), or employees. Schedule and census will be monitored daily per shift by RN Nursing Supervisor for call offs and changes in census. Adjustments will be made as needed by Director of Nursing, RN Nursing Supervisor, or Staffing Coordinator. Facility will utilize facility staff and/or temporary Staffing Agencies to fill in shifts as needed according to type of nursing service personnel that is needed. Assistant Administrator or designee will monitor schedules at least weekly x 4 weeks and then every 2 weeks until deemed in compliance by facility QAPI Committee.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified during a review of nursing staffing documents for the period from August 1, 2024, to August 7, 2024, where it was found that on August 7, 2024, the facility provided only 3.16 hours of direct care per resident. The Nursing Home Administrator confirmed the accuracy of the staffing information and acknowledged the failure to meet the required care hours on the specified date.
Plan Of Correction
Facility Staffing Coordinator was reeducated on current nursing care hours provided according to current census and shifts. Facility will attempt to utilize facility staff and temporary staffing agencies as needed. Facility weekly Schedule will be made in accordance with current Pennsylvania DOH Staffing guidelines and facility census. Nursing Supervisors to be in-serviced on staffing guidelines by 1/8/2025. For the date indicated all residents in the facility received the care that they required, and the facility received no complaints from residents, their responsible person(s) or employees. Schedule and census will be monitored daily per shift by RN Nursing Supervisor for call offs and changes in census. Adjustments will be made as needed by Director of Nursing, RN Nursing Supervisor or Staffing Coordinator. Facility will utilize facility staff and or temporary Staffing Agencies to fill in shifts as needed to comply with current nursing care hours in a 24-hour period. Assistant Administrator or designee will monitor schedules at least weekly x 4 weeks and then every 2 weeks until deemed in compliance by facility QAPI Committee.
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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