Homewood Living Martinsburg, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Martinsburg, Pennsylvania.
- Location
- 437 Givler Drive, Martinsburg, Pennsylvania 16662
- CMS Provider Number
- 395896
- Inspections on file
- 28
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Homewood Living Martinsburg, Inc during CMS and state inspections, most recent first.
The facility failed to update care plans for two residents with specific medical needs. One resident with a midline catheter did not have related care interventions in their plan, and another resident diagnosed with epilepsy lacked a seizure disorder care plan. These omissions were confirmed by the DON.
A facility failed to update a resident's care plan to reflect the need for diuretic medication, despite the resident receiving Furosemide as ordered. The resident, who was cognitively impaired and had diagnoses including respiratory failure and hypertension, required assistance with care needs. The deficiency was confirmed by the DON.
A resident in an LTC facility was mistakenly given another resident's medication due to a staff member's distraction. The resident, who had renal failure and dementia, received multiple incorrect medications and was sent to the ER for evaluation. The incident was confirmed by the DON.
The facility failed to ensure a safe environment and proper resident handling, as evidenced by a hot plate accessible to residents and improper wheelchair transport and transfer techniques. A resident accessed hot water from a hot plate, and another was transported without leg rests. Additionally, a resident was assisted to stand without a gait belt, contrary to policy. The DON was unaware of these issues.
A resident with cognitive impairment and significant weight loss did not have their weight documented on multiple occasions, despite physician's orders for weekly weigh-ins. The resident was on a mechanically altered diet and had several medical conditions, including dementia and respiratory failure. The DON confirmed the weights were not obtained as ordered.
A facility failed to obtain necessary documentation from a hospice provider for a resident receiving end-of-life care. Despite the resident's cognitive impairment and need for assistance, there was no evidence of progress notes from hospice staff in the clinical record. The DON confirmed that hospice communication records should have been accessible but were not.
A registered nurse failed to follow infection control procedures during incontinent care for a resident with moderate cognitive impairment and dementia. The nurse did not remove gloves or perform hand hygiene after providing care and before assisting the resident further, contrary to the facility's hand hygiene policy. Both the nurse and the DON confirmed the lapse in procedure.
The facility failed to follow physician's orders for two residents, leading to significant deficiencies. One resident received another's medication, resulting in hospitalization for bradycardia and hypotension. Another resident did not receive Zoloft for two weeks due to transcription errors. The DON confirmed the errors in both cases.
Failure to Update Care Plans for Residents with Specific Medical Needs
Penalty
Summary
The facility failed to develop individualized care plans for two residents, which is a requirement according to their policy for Comprehensive, Person-Centered Care Plans. Resident 28, who was cognitively impaired and required assistance with care needs, had a midline catheter for intravenous access. However, the resident's care plan did not include any information or interventions related to the care and use of the midline catheter. This omission was confirmed by the Director of Nursing during an interview. Similarly, Resident 105 experienced two seizure episodes and was subsequently diagnosed with epilepsy after being admitted to the hospital. Despite this significant change in the resident's condition, the care plan did not include any information or interventions related to the resident's seizure disorder. This deficiency was also confirmed by the Director of Nursing. The lack of updated care plans for these residents indicates a failure to meet the facility's policy requirements for comprehensive, person-centered care planning.
Failure to Update Resident Care Plan for Diuretic Medication
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect the resident's specific care needs. The deficiency was identified for one of the 44 residents reviewed, specifically Resident 25. The facility's policy for Comprehensive Person-Centered Care Plans requires that care plans be revised as information about the resident's condition changes. However, the care plan for Resident 25 was not updated to include the need for diuretic medication, despite the resident receiving Furosemide as ordered. Resident 25 was cognitively impaired, required assistance with care needs, and had diagnoses including respiratory failure and hypertension. The resident's quarterly Minimum Data Set assessment indicated the need for diuretic medication, which was confirmed by current physician's orders. Despite this, there was no documented evidence that the care plan was revised to reflect the resident's need for diuretic medication. This was confirmed during an interview with the Director of Nursing.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were administered correctly to a resident, identified as Resident 89. The incident involved a staff member who became distracted and mistakenly administered another resident's medication to Resident 89. This error was documented in a nursing note dated October 21, 2024, at 10:15 p.m. The resident, who was cognitively impaired and required assistance with care needs, had diagnoses including renal failure and dementia. Following the medication error, Resident 89 was sent to the emergency room for further evaluation and treatment to monitor for any possible drug interactions. The medications incorrectly administered to Resident 89 included Tylenol, Zyprexa, Atorvastatin, Famotidine, Levetiracetam, Lithium, Hydroxychloroquine, and Effexor. An interview with the Director of Nursing confirmed the medication error and the subsequent hospital evaluation. The report highlights the failure in medication administration, which was identified as past non-compliance during the review of clinical records, observations, and staff interviews.
Failure to Maintain Safe Environment and Proper Resident Handling
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, as evidenced by the presence of a hot plate in the main dining room that was accessible to residents. Observations revealed that a resident was able to pour hot water from a coffee pot placed on the hot plate, which was at waist height and within reach. Interviews with the resident, a family member, and a dietary aide confirmed that typically staff serve hot beverages to residents, but the hot plate's accessibility posed a potential hazard. The Director of Nursing was unaware of the hot plate's location and acknowledged the need for its immediate removal. Additionally, the facility did not adhere to its policy regarding the safe transportation of residents in wheelchairs. A cognitively impaired resident, dependent on staff for mobility, was transported without leg rests, causing her feet to drag. Nurse aides involved in the transport confirmed the oversight, and the Director of Nursing acknowledged the requirement for leg rests. Furthermore, a resident with moderate cognitive impairment was assisted to stand and walk without the use of a gait belt, contrary to facility policy. The registered nurse involved confirmed the omission, and the Director of Nursing acknowledged the necessity of using a gait belt for safe resident transfers.
Failure to Obtain Resident Weights as Ordered
Penalty
Summary
The facility failed to obtain weights as ordered by the physician for a resident who experienced weight loss. The resident, who was cognitively impaired and required supervision with eating, was on a mechanically altered diet and had a significant weight loss. The resident also received diuretic medication, oxygen, and had diagnoses of dementia, depression, anxiety, and respiratory failure. Physician's orders required the resident to be weighed weekly over several specified periods, but the facility did not document the resident's weight on multiple occasions. Specifically, the resident's weight was not documented on August 19, September 9, October 18, and November 14, 2024, despite physician's orders to do so. An interview with the Director of Nursing confirmed that the weights were not obtained as ordered on these dates. This failure to follow physician's orders for weight monitoring was identified as a deficiency in the facility's nursing services.
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the required information was obtained from the contracted hospice provider for a resident receiving hospice services. The facility's policy indicated that the hospice agency is responsible for the professional management of the plan of care related to the terminal illness and must communicate any changes to the facility. However, there was no documented evidence of progress notes from the hospice registered nurse or the hospice nurse aide in the resident's clinical record since the start of hospice services. The resident in question was cognitively impaired, required assistance for daily care needs, and had diagnoses including dementia and Alzheimer's disease. Despite being admitted to hospice services, the facility did not have the necessary hospice communication records readily accessible in the resident's clinical record. The Director of Nursing confirmed that it was the facility's practice to obtain paperwork from hospice agencies weekly, but this was not done in this case.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to consistently implement infection control procedures during incontinent care for a resident. The facility's policy on hand hygiene, dated January 10, 2024, emphasizes hand hygiene as the primary means to prevent the spread of healthcare-associated infections. It requires hand hygiene after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal. An observation on November 18, 2024, revealed that a registered nurse did not follow these procedures while providing care to a resident with moderate cognitive impairment and dementia. During the incident, the registered nurse assisted the resident, who was both continent and incontinent of urine, by removing a soiled brief and changing the resident's soiled pants. The nurse then cleansed the resident's buttocks area and assisted the resident to a standing position without removing her gloves or performing hand hygiene. The nurse continued to assist the resident by rubbing her back and helping her to sit in a recliner, still without removing her gloves. Both the nurse and the Director of Nursing confirmed that the nurse should have removed her gloves and performed hand hygiene after providing toileting care and before touching the resident's belongings.
Medication Administration and Transcription Errors
Penalty
Summary
The facility failed to follow physician's orders and properly administer medication for two residents, leading to significant deficiencies. For one resident, who was cognitively impaired and had Alzheimer's disease, the facility administered another resident's medication, which included Lopressor, Senna, Cardizem, Gabapentin, and Seroquel. This error resulted in the resident experiencing bradycardia, hypotension, and a nosocomial overdose, necessitating hospitalization and admission to the ICU for observation. The Director of Nursing confirmed that the medication nurse did not verify the resident's identity before administering the medication. In another case, the facility failed to transcribe a physician's order correctly for a resident who was also cognitively impaired and had Alzheimer's disease. A verbal order for Zoloft was taken by a registered nurse, but the medication was discontinued in error, and the incorrect start date was recorded. As a result, the resident did not receive the prescribed Zoloft for two weeks. The Director of Nursing confirmed that the registered nurse should have verified the medication transcription to ensure accuracy.
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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