Jameson Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Castle, Pennsylvania.
- Location
- 3349 Wilmington Road, New Castle, Pennsylvania 16105
- CMS Provider Number
- 396049
- Inspections on file
- 22
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Jameson Nursing And Rehab Center during CMS and state inspections, most recent first.
A resident with Type 2 diabetes did not receive the prescribed medication, Janumet, due to its unavailability upon admission. The LPN noted the medication had not arrived from the pharmacy, resulting in the resident missing three doses. The Nursing Home Administrator and DON confirmed the failure to administer the medication as ordered.
The facility did not meet the required nurse aide (NA) to resident ratios on multiple occasions. On several days, the day shift was understaffed, with fewer NAs than required for the number of residents. Additionally, the evening shift on one day was also understaffed. The Nursing Home Administrator confirmed these staffing shortages.
The facility did not meet the required minimum nurse aide (NA) to resident ratio during the day shift for six days. For example, with a census of 69 residents, only 5.09 NAs worked when 6.90 were required. These shortages were confirmed by the Nursing Home Administrator and DON.
The facility did not meet the required LPN staffing ratios during a day shift, with only 2.23 LPNs available for 64 residents, instead of the required 2.56. This deficiency was confirmed by the Nursing Home Administrator.
A facility failed to transcribe and administer physician's orders for an anticoagulant medication and a dressing change for a resident with a fractured hip. The resident's records lacked evidence of Lovenox administration and dressing changes as ordered, which was confirmed by the Nursing Home Administrator and the Director of Nursing.
A resident with a non-weight bearing condition was improperly transferred by a single nurse aide, contrary to the care plan requiring two-person assistance. The aide called for help but did not receive assistance, resulting in the resident being lowered to the floor. The facility's investigation confirmed the neglect due to failure to follow the care plan.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to administer a prescribed medication, Janumet, to a resident, identified as R227, according to the physician's orders. The resident, who was admitted with diagnoses including a right hip fracture, arthritis, anxiety disorder, and Type 2 diabetes, had a physician's order for Janumet 50/500 mg to be taken orally twice daily starting on the morning of February 19, 2025. However, during a medication administration observation on the same day, it was noted that the medication was not available, and the Licensed Practical Nurse (LPN) stated that the medication had not yet arrived from the pharmacy. There was no evidence of follow-up with the physician regarding the unavailability of the medication. The resident missed three doses of Janumet, including both doses on February 19 and the morning dose on February 20. This was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged the failure to administer the medication as ordered. The deficiency was noted under the regulations concerning medical records, pharmacy services, and nursing services.
Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios on several occasions, as evidenced by a review of nursing staffing documents and staff interviews. Specifically, on three out of six days reviewed, the facility did not have the minimum of one NA per 10 residents during the day shift. On January 29, 2025, with a census of 69 residents, only 6.07 NAs worked when 6.90 were required. On February 2, 2025, with 68 residents, 6.07 NAs worked when 6.80 were required. On February 3, 2025, with 69 residents, only 4.89 NAs worked when 6.90 were required. Additionally, on February 3, 2025, during the evening shift, the facility had a census of 68 residents but only 4.63 NAs worked when 6.18 were required. The Nursing Home Administrator confirmed these staffing shortages during an interview on February 4, 2025.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. The facility cannot correct that the nurse aide staffing ratio was not met on 1/29/25, 2/2/25 and 2/3/25. There were no adverse effects to residents on the identified dates. 2. The scheduler will be re-educated regarding the state ratios by the Nursing Home Administrator/designee. 3. The Director of Nursing and RN Supervisors will be re-educated on staffing ratios by the Nursing Home Administrator/designee. 4. Twice a day staffing meetings will be held Monday through Friday to review the schedule with ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the scheduler/or designee will call off duty facility staff and will utilize pick up bonuses. 5. The facility has developed a monthly recruitment and retention committee meeting. 6. Nurse Aide positions are actively posted in recruitment. 7. Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. 8. Admission intake will be reviewed in relationship to staffing. 9. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) to resident ratio during the day shift for six out of 21 days reviewed. Specifically, on the dates of 12/22/24, 12/23/24, 12/24/24, 12/25/24, 12/28/24, and 12/29/24, the facility did not have enough NAs working to meet the regulatory requirement of one NA per 10 residents. For instance, on 12/22/24, with a census of 67 residents, only 5.90 NAs worked when 6.70 were required. Similarly, on 12/24/24, with a census of 69 residents, only 5.09 NAs worked when 6.90 were required. These shortages were confirmed by the Nursing Home Administrator and Director of Nursing during an interview on 12/30/24.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. The facility cannot correct that the Nurse Aide staffing ratio was not met on 12/22, 12/23, 12/24, 12/25, 12/28 and 12/29. 2. Weekend nursing supervisors and scheduler will be re-educated regarding the state ratios by the Director of Nursing/ designee. 3. Schedule with ratios are reviewed at our stand-up meeting. 4. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios the scheduler/or designee will call off duty facility staff, notify Director of Nursing and will utilize pick-up bonuses. 5. All nursing positions are actively posted in recruitment and are sponsored ads. 6. Facility will hold a recruitment/retention committee. 7. Facility will hold open interviews. 8. Call offs will continue to be monitored and disciplines will be issued, as appropriate. 9. Director of Nursing/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. 10. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations. 11. Accepting new admissions will depend on staffing levels.
LPN Staffing Shortage on Day Shift
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) during the day shift on December 7, 2024. According to the regulation effective July 1, 2023, the facility must have a minimum of one LPN per 25 residents during the day. On the specified date, the facility had a census of 64 residents, necessitating 2.56 LPNs, but only 2.23 LPNs were on duty. This staffing shortage was confirmed by the Nursing Home Administrator during an email correspondence interview on December 23, 2024.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. The facility cannot correct that the Licensed Practical Nursing staffing ratio was not met during one shift on 12/7/24. There were no adverse effects to residents on the identified date. 2. Weekend nursing supervisors and scheduler will be re-educated regarding the state ratios by the Director of Nursing/ designee. 3. Schedule with ratios are reviewed at our stand-up meeting. 4. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the scheduler/or designee will call off duty facility staff, notify Director of Nursing, and will utilize pick-up bonuses. 5. All nursing positions are actively posted in recruitment and are sponsored ads. 6. Facility will hold a recruitment/retention committee. 7. Call offs will continue to be monitored and disciplines will be issued, as appropriate. 8. Director of Nursing/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. 9. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations. 10. Accepting new admissions will depend on staffing levels.
Failure to Transcribe and Administer Medication and Dressing Change Orders
Penalty
Summary
The facility failed to transcribe and administer physician's orders for an anticoagulant medication and a dressing change for a resident. The resident, who was admitted with diagnoses including anemia, atelectasis, and a fractured right hip, had a documented order from a hospital to receive Lovenox, an injectable anticoagulant, daily for 30 days. However, the facility's records, including the Medication Administration Record (MAR), lacked evidence that Lovenox was transcribed and administered on two specific dates. This oversight was confirmed by the Nursing Home Administrator during an interview. Additionally, the resident's clinical record included a hospital document indicating a daily dressing change for a surgical incision on the right hip. Despite this, the facility's records, including the Treatment Administration Record (TAR), did not show that the dressing change order was transcribed or executed. The Director of Nursing confirmed the failure to transcribe the dressing change order and the lack of evidence that the facility sought clarification from the primary care physician or surgeon to ensure proper care was provided.
Neglect Due to Improper Transfer of Resident
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, as evidenced by an incident involving a resident who required extensive assistance with transfers due to a non-weight bearing condition. The resident, who had a history of a fracture of the head and neck of the left femur, atrial fibrillation, and heart failure, was incorrectly transferred by a single nurse aide after receiving a shower. Despite the care plan indicating that the resident required the assistance of two staff members for transfers, the nurse aide attempted to transfer the resident alone, resulting in the resident being lowered to the floor. The incident occurred when the nurse aide, after completing the shower, attempted to move the resident without the required assistance. The aide called for help multiple times but did not receive any response, leading to the resident being placed on the floor. The facility's investigation revealed that the nurse aide did not use the call bell for assistance and failed to follow the resident's care plan, which contributed to the neglect. The resident was found on the tile floor, but no harm or injury was reported.
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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